Child Monitoring Sheet

Child's name: ____

Date of birth:

Instructions: You may use this form to track a child’s ASQ screening results over time. Write the date the ASQ was administered and questionnaire month at the top of each column. Fill in the bubble that corresponds with the score for each developmental area (refer to the completed ASQ-3 Information Summary). If a score is above the monitoring zone, mark the bubble for “Well Above.” If a score is within the monitoring zone but above the cutoff, mark “Monitor.” If a score is at or below the cutoff, mark “Below.” Also mark whether there were items of concern in the Overall section for each questionnaire (bolded uppercase on the ASQ-3 Information Summary).