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

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 tell you at least two things about common objects?(Required)

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"?

2. Does your child use all of the words in a sentence to make a complete sentance?(Required)

For example, "a", "the", "am", "is", and "are" to make complete sentences such as "I am going to the park," "Is there a toy to play with?" or "Are you coming too?"

3. 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"?

4. 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."

5. Does your child use four and five word sentences?(Required)

For example, does your child say "I want the car"?

6. When talking about something that already happened, does your child use words that end in "-ed", such as "walked", "jumped", or "played"?(Required)

Ask your child questions, such as "How did you get to the store?" ("we walked") "What did you do at your friend's house?" ("We played")

Gross Motor

7. 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)

8. 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")

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

10. 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.

11. 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.

12. Does your child walk on his tiptoes for 15 feet (about the length of a large car)?(Required)

You may show him how to do this.

Fine Motor

13. 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.

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

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

15. 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.

16. Ask your child to trace on a line with a pencil. Does your child trace on the line without going off the line more than two times?(Required)

Mark "sometimes" if your child goes off the line three times.

17. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, "Draw a picture of a girl or boy."(Required)

If your child draws a person with head, body, arms, and legs mark "yes". If your child draws a person with only three parts (head, body, arms, or legs), mark "sometimes". If your child draws a person with two or fewer parts (head, body, arms, or legs), mark "not yet".

18. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades goup and down?(Required)

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

Problem Solving

19. 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.

20. 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.

21. 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.

22. 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.

23. Does your child count up to 15 without making mistakes?(Required)

If so, mark "yes". If your child counts to 12 without making mistakes, mark "sometimes".

24. Does your child know the names of numbers?(Required)

Mark "yes" if he identifies the three numbers below. Mark "sometimes" if he identifies two numbers.

Personal-Social

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

26. 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.

27. 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.

28. 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?

29. 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

30. Does your child dress and undress himself, including buttoning medium-sized buttons and zipping from zippers?(Required)

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