# Ages & Stages® Questionnaires

### 36 Month Questionnaire

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

- **Date ASQ completed:**

### Child’s information

- **Child’s first name:**  
- **Child’s last name:**  
- **Child’s gender:**  
  - Male  
  - Female

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### Month Questionnaire
36

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

#### Important Points to Remember:

- ☑️ Try each activity with your baby 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.

### COMMUNICATION

1. When you ask your child to point to her nose, eyes, hair, feet, ears, and so forth, does she correctly point to at least seven body parts? (She can point to parts of herself, you, or a doll. Mark “sometimes” if she correctly points to at least three different body parts.)  
2. Does your child make sentences that are three or four words long?  
   **Please give an example:**

3. Without giving your child help by pointing or using gestures, ask him to “put the book on the table” and “put the shoe under the chair.” Does your child carry out both of these directions correctly?

4. When looking at a picture book, does your child tell you what is happening or what action is taking place in the picture (for example, “barking,” “running,” “eating,” or “crying”)? You may ask, “What is the dog (or boy) doing?”

### GROSS MOTOR

1. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?  
2. Does your child jump with both feet leaving the floor at the same time?  
3. Does your child walk up stairs, using only one foot on each stair? (The left foot is on one step, and the right foot is on the next.) She may hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)  
4. Does your child stand on one foot for about 1 second without holding onto anything?  
5. While standing, does your child throw a ball overhand by raising his arm to shoulder height and throwing the ball forward? (Dropping the ball or throwing the ball underhand should be scored as “not yet.”)

6. After your child watches you draw a line from the top of the paper to the bottom with a pencil, crayon, or pen, ask her to make a line like yours. (Do not let your child trace your line.)  
7. Does your child jump forward at least 6 inches with both feet leaving the ground at the same time?

### FINE MOTOR

1. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?  
2. After your child watches you draw a single circle, ask him to make a circle like yours. (Do not let him trace your circle.)  
3. After your child watches you draw a line from one side of the paper to the other side, ask her to make a line like yours. (Do not let your child trace your line.)  
4. Does your child try to cut paper with child-safe scissors? He does not need to cut the paper but must get the blades to open and close while holding the paper with the other hand. (You may show your child how to use scissors. Carefully watch your child’s use of scissors for safety reasons.)  
5. When drawing, does your child hold a pencil, crayon, or pen between her fingers and thumb like an adult does?  
6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row?  
7. If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?

### PROBLEM SOLVING

1. When you point to the figure and ask your child, “What is this?” does your child say a word that means a person or something similar? (Mark “yes” for responses like “snowman,” “boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)  
   **Please write your child’s response here:**

2. When you say, “Say ‘seven three,’” does your child repeat just the two numbers in the same order?  
3. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order?

### PERSONAL-SOCIAL

| PERSONAL-SOCIAL | YES | SOMETIMES | NOT YET |
| --- | --- | --- | --- |
| 1. Does your child use a spoon to feed herself with little spilling? | ○ | ○ | ○ |
| 2. Does your child push a little wagon, stroller, or toy on wheels, steering it around objects and backing out of corners if he cannot turn? | ○ | ○ | ○ |
| 3. When your child is looking in a mirror and you ask, “Who is in the mirror?” does she say either “me” or her own name? | ○ | ○ | ○ |
| 4. Does your child put on a coat, jacket, or shirt by himself? | ○ | ○ | ○ |
| 5. Using these exact words, ask your child, “Are you a girl or a boy?” Does your child answer correctly? | ○ | ○ | ○ |
| 6. Does your child take turns by waiting while another child or adult takes a turn? | ○ | ○ | ○ |

### OVERALL

Parents and providers may use the space below for additional comments.

1. Do you think your child hears well?  
   **If no, explain:**

2. Do you think your child talks like other children her age?  
   **If no, explain:**

3. Does either parent have a family history of childhood deafness or hearing impairment?  
   **If yes, explain:**

4. Do you have any concerns about your child’s vision?  
   **If yes, explain:**

5. Has your child had any medical problems in the last several months?  
   **If yes, explain:**

6. Do you have any concerns about your child’s behavior?  
   **If yes, explain:**

7. Does anything about your child worry you?  
   **If yes, explain:**

### Month ASQ-3 Information Summary
36

- **Child's name:**  
- **Date ASQ completed:**  
- **Date of birth:**  
- **Child's ID #:**

1. SCORE AND TRANSFER TOTALS TO CHART BELOW: Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.

| Area | Cutoff | Total Score | 0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Communication | 30.99 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Gross Motor | 36.99 |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Fine Motor | 18.07 |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Problem Solving | 30.29 |  |  |  |  |  |  |  |  |  |  |  |  |  |
| Personal-Social | 35.33 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |