Ages & Stages Questionnaire

Please fill out the form below.

On the form below are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet.

For each item, please select the option that indicates whether your child is doing the activity regularly, sometimes, or not yet.

Try each activity with your child before marking a response.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is rested and fed.

Ages & Stages Questionnaire

Ages and Stages Questionnaire

On the form below are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please select the option that indicates whether your child is doing the activity regularly, sometimes, or not yet.

Try each activity with your child before marking a response
Make completing this questionnaire a game that is fun for you and your child
Make sure your child is rested and fed

Child's Date of Birth(Required)

Child's First Name(Required)

Child's Last Name(Required)

Date ASQ Completed(Required)

Who is completing the ASQ(Required)

Communication

1. Does your child name at least three items from a common category?(Required)

For example, if you say to your child, "Tell me some things that you can eat," does your child answer with something like "cookies, eggs, and cereal?" Or if you say, "Tell me the names of some animals," does your child answer with something like "cow, dog, and elephant"?

2. Does your child answer the following questions? (Mark "sometimes" if your child answers only one question.)(Required)

What do you do when you are hungry? What do you do when you are tired?

3. Does your child tell you at least two things about common objects?(Required)

For example, if you say to your child, "Tell me about your ball," does she say something like "It's round. I throw it. It's big"?

4. Does your child use endings of words such as "-s", "-ed", and "-ing"?(Required)

For example, does your child say things like, "I see two cats", "I am playing" or "I kicked the ball"?

5. Without your giving help by pointing or repeating, does your child follow three directions that are unrelated to one another?(Required)

Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."

6. Does your child use all of the words in a sentence (for example, "a," "the," "am," "Is," and "are") to make complete sentences.(Required)

Examples are "I am going to the park" or "Is there a toy to play with?" or "Are you coming, too?"

Gross Motor

7. Does your child catch a large ball with both hands?(Required)

You should stand about 5 feet away and give your child two or three tries before you mark the answer.

8. Does your child climb the rungs of a ladder of a playground slide and slide down without help?(Required)

9. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away?(Required)

To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as "not yet")

10. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?(Required)

11. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?(Required)

12. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down?(Required)

You may give your child two or three tries before you mark the answer.

Fine Motor

13. Does your child put together a five-to-seven-piece interlocking puzzle?(Required)

If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?

14. Using child-safe scissors, does your child cut a paper in half on a more or less straight line?(Required)

Carefully watch your child's use of scissors for safety reasons.

15. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, without tracing?(Required)

Your child's drawings should look similar to the design of the shapes below, but they may be different in size.

16. Does your child unbutton one or more buttons?(Required)

Your child may use his own clothing or a doll's clothing.

17. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?(Required)

18. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw?(Required)

Your child should not go more than 1/4 inch outside the lines on most of the picture.

Problem Solving

19. When you say "Say, five eight three," does your child repeat just the three numbers in the same order?(Required)

Do not repeat the numbers. If necessary, try another series of numbers and say "Say 'six nine two." (Your child must repeat just one series of three numbers to answer "yes" to this question.)

20. When asked, "Which circle is the smallest?" does your child point to the smallest circle?(Required)

Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.

21. Without your giving help by pointing, does your child follow three different directions using the words "under", "between", and "middle"?(Required)

For example, ask your child to put the shoe "under the couch." Then ask her to put the ball "between the chairs" and the book "in the middle of the table."

22. When shown objects and asked, "What color is this?" does your child name five different colors like red, blue, yellow, black, white, or pink?(Required)

Mark "yes" only if your child answers the question correctly using five colors.

23. Does your child dress up and "play-act", pretending to be someone or something else?(Required)

For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.

24. If you place five objects in front of your child, can he count them by saying "one, two, three, four, five" in order?(Required)

Ask this question without providing help by pointing, gesturing, or naming.

Personal-Social

25. Does your child serve herself, taking food from one container to another using utensils?(Required)

For example, does your child use a large spoon so scoop applesauce from a jar into a bowl?

26. Does your child tell you at least four of the following? Please mark the items your child knows.(Required)

Personal Social Q2 Breakdown(Required)

First name

Last name

Age

Boy or Girl

City she lives in

Telephone number

None of the above

27. Does your child wash his hands using soap and water and dry off with a towel without help?(Required)

28. Does your child tell you the names of two or more playmates, not including brothers and sisters?(Required)

Ask this question without providing help by suggesting names of playmates or friends.

29. Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of her teeth without help?(Required)

You may still need to check and re=brush your child's teeth.

30. Does your child dress and undress himself without help (except for snaps, buttons, and zippers)?(Required)

You may still need to check and re=brush your child's teeth.

Overall

31. Do you think your child hears well?(Required)

Why do you not think they do not hear well?

32. Do you think your child talks like other children her age?(Required)

Why do you think your child does not talk like other children her age?

33. Can you understand most of what your child says?(Required)

Please explain how/why you cannot understand what your child says.

34. Can other people understand most of what your child says?(Required)

Please explain how/why others cannot understand what your child says.

35. Do you think your child walks, runs, and climbs like other children his age?(Required)

Please explain why you think your child does not walk, run, or climb like other children their age.

36. Does either parent have a family history of childhood deafness or hearing impairment?(Required)

Please explain the family history of childhood deafness or hearing impairment.

37. Do you have any concerns about your child's vision?(Required)

What concerns do you have about your child's vision?

38. Has your child had any medical problems in the last several months?(Required)

Please explain what medical problems your child has had in the last several months.

39. Do you have any concerns about your child's behavior?(Required)

What concerns do you have about your child's behavior?

40. Does anything about your child worry you?(Required)

What worries you?

Communication Score