36 Month 2

Questionnaire
33 months 0 days through 41 months 30 days S E CO N D E D I T I O N

Date ASQ:SE-2 completed: ___04/25/2023_______________________________________________

Child’s information

Child’s first name: EYAS Child’s middle initial: DARWEESH Child’s last name: DARWEESH

Child’s date of birth: 07/04/2020

Child’s gender: x Male ◯ Female

Person filling out questionnaire

First name: DARWEESH Middle initial: . Last name: DARWEESH

Street address: 1500 W PLUM STREETS

State/
City: FORT COLLINS province: COLORADO ZIP/postal code:80521
Home Other
telephone telephone
Country: USA number: 9708037879 number: 9704024684

E-mail address:
Relationship to child: x Parent ◯ Guardian ◯ Teacher ◯ Other:
◯ other relative ◯ Foster
Grandparent/
parent
◯ Child care
provider

People assisting in questionnaire completion:

Program information (For program use only.)

Age at administration
Child’s ID #: in months and days:

Program ID #:

Program name:

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.
P201360000 © 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.
 36 Month Questionnaire 33 months 0 days through 41 months 30 days 2
Questions about behaviors children may have are listed on the following pages. Please read each question carefully and check the
box that best describes your child’s behavior. Also, check the circle if the behavior is a concern.

Important Points to Remember:

❏ Answer questions based on what you know about your ❏ Please return this questionnaire by: ___________________
child’s behavior.
❏ If you have any questions or concerns about your child or
❏ Answer questions based on your child’s usual behavior, about this questionnaire, contact: ____________________
not behavior when your child is sick, very tired, or hungry.
❏ Thank you and please look forward to filling out another
❏ Caregivers who know the child well and spend more than ASQ:SE-­2 in _________ months.
15–­20 hours per week with the child should complete ASQ:SE-­2.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

1. Does your child look at you when you talk to her? x z ☐v ☐x ◯v _____

2. Does your child like to be hugged or cuddled? x z ☐v ☐x ◯v _____

3. Does your child talk or play with adults he knows well? x z ☐v ☐x ◯v _____

4. Does your child cling to you more than you expect?

☐x x v ☐z ◯v _____

5. When upset, can your child calm down within 15 minutes? x z ☐v ☐x ◯v _____

6. Does your child seem too friendly with strangers? x x ☐v ☐z ◯v _____

7. Does your child settle herself down after exciting activities? x z ☐v ☐x ◯v _____

TOTAL POINTS ON PAGE  _____

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36 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

8. Does your child move from one activity to the next with little x z ☐v ☐x ◯v _____
difficulty (for example, from playtime to mealtime)?

9. Does your child seem happy? x z ☐v ☐x ◯v _____

10. Is your child interested in things around him, such as people, toys, x z ☐v ☐x ◯v _____
and foods?

11. Does your child do what you ask her to do? x z ☐v ☐x ◯v _____

12. Does your child seem more active than other

☐x x v ☐z ◯v _____
children his age?

13. Does your child stay with activities she enjoys for at least x z ☐v ☐x ◯v _____
5 minutes (other than watching shows or videos, or playing with
electronics)?

14. Do you and your child enjoy mealtimes together? x z ☐v ☐x ◯v _____

15. Does your child have eating problems? For example, does he
☐x ☐v x z ◯v _____
stuff food, vomit, eat things that are not food, or ________?
(Please describe.)

____________________________________________________________

____________________________________________________________

16. Does your child sleep at least 8 hours in a 24-­hour period? x z ☐v ☐x ◯v _____

17. Does your child use words to tell you what she wants or needs?
☐z x v ☐x ◯v _____

TOTAL POINTS ON PAGE  _____

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36 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

18. Does your child follow routine directions? For example, does he x z ☐v ☐x ◯v _____
come to the table or help clean up his toys when asked?

19. Does your child cry, scream, or have tantrums for long
☐x ☐v x z ◯v _____
periods of time?

20. Does your child check to make sure you are near
☐z x v ☐x ◯v _____
when exploring new places, such as a park or
a friend’s home?

21. Does your child do things over and over and get upset when you x x ☐v ☐z ◯v _____
try to stop her? For example, does she rock, flap her hands, spin,
or ________? (Please describe.)

____________________________________________________________

____________________________________________________________

22. Does your child hurt himself on purpose?

☐x ☐v x z ◯v _____

23. Does your child stay away from dangerous things, such as fire and
☐z ☐v x x ◯v _____
moving cars?

24. Does your child destroy or damage things on purpose?

☐x ☐v x z ◯v _____

25. Does your child use words to describe her feelings and the
☐z x v ☐x ◯v _____
feelings of others? For example, does she say, “I’m happy,”
“I don’t like that,” or “She’s sad”?

26. Can your child name a friend?

☐z x v ☐x ◯v _____

TOTAL POINTS ON PAGE  _____

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36 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

27. Do other children like to play with your child? x z ☐v ☐x ◯v _____

28. Does your child like to play with other children? x z ☐v ☐x ◯v _____

29. Does your child try to hurt other children, adults, or animals (for
☐x ☐v x z ◯v _____
example, by kicking or biting)?

30. Does your child show an unusual interest in or knowledge of

☐x ☐v x z ◯v _____
sexual language and activity?

31. Does your child try to show you things by pointing at them and
☐z ☐v x x ◯v _____
looking back at you?

32. Does your child pretend objects are something else? For example, x z ☐v ☐x ◯v _____
does he pretend a banana is a phone?

33. Does your child wake three or more times during the night?
☐x x v ☐z ◯v _____

34. Is your child too worried or fearful? If “sometimes” or “often or

☐x ☐v x z ◯v _____
always,” please describe:

____________________________________________________________

____________________________________________________________

____________________________________________________________

35. Has anyone shared concerns about your child’s behaviors? If

☐x ☐v x z ◯v _____
“sometimes” or “often or always,” please explain:

____________________________________________________________

____________________________________________________________

____________________________________________________________

TOTAL POINTS ON PAGE  _____

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36 Month Questionnaire 2

OVERALL Use the space below for additional comments.

36. Do you have concerns about your child’s eating, sleeping, or toileting habits?
If yes, please explain: ◯ YES ◯ NO

about toileting he know about what he shoulde doing in bathroom

___________________________________________________________________________________________________________
but he concern when he sit in toilet but i
___________________________________________________________________________________________________________
thenk i have time to solved this problem
___________________________________________________________________________________________________________

37. Does anything about your child worry you? If yes, please explain: ◯ YES ◯ NO
No
___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

38. What do you enjoy about your child?

when he wakeup his morning so funny and have a bositeve energy

___________________________________________________________________________________________________________

when he says morning my heart gets out of place, and he always have a full energy my kids super active
___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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