Asq 54 Month Questionnaire – Fill Out and Use This PDF

Enter the Date ASQ completed.

Use black or blue ink only and print legibly when completing this form.

Under Child's information, enter the Child's first name, Middle initial, Child's last name and Child's date of birth, and mark Male or Female for Child's gender.

For the Person filling out questionnaire, enter First name, Last name and Middle initial, and mark the Relationship to child: Parent, Guardian, Grandparent or other relative, Foster parent, Teacher, Child care provider or Other.

Enter the Street address, City, State/ Province, ZIP/ Postal code, Country, Home telephone number, Other telephone number and E-mail address.

Enter the Names of people assisting in questionnaire completion.

Under Program Information, enter the Child ID #, Program ID # and Program name.

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

Your child may have already done some of the activities described here, and there may be some your child has not begun doing 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.

Please return this questionnaire by _______________.

GROSS MOTOR 2: dropping the ball or throwing the ball underhand should be scored as "not yet."

FINE MOTOR 4: your child traces on the line without going off the line more than two times; mark "sometimes" if your child goes off the line three times.

FINE MOTOR 5: 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."

Be sure to include the sheet of paper with your child's drawing with this questionnaire.

PROBLEM SOLVING 5: if your child counts up to 15 without making mistakes, mark "yes." If your child counts to 12 without making mistakes, mark "sometimes."

PROBLEM SOLVING 6: mark "yes" if he identifies the three numbers. Mark "sometimes" if he identifies two numbers.

OVERALL 1 to 5: mark YES or NO. If no, explain.

OVERALL 6 to 10: mark YES or NO. If yes, explain.

Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.

See ASQ-3 User's Guide for details, including how to adjust scores if item responses are missing.

Bolded uppercase responses require follow-up.

You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.

Under FOLLOW-UP ACTION TAKEN, check all that apply: Provide activities and rescreen in a number of months, Share results with primary health care provider, Refer for hearing, vision, and/or behavioral screening, Refer to primary health care provider or other community agency, Refer to early intervention/early childhood special education, No further action taken at this time, or Other (specify).

On the following pages are questions about activities children may do.