Ages & Stages® Questionnaires

48 Month Questionnaire

Date ASQ completed: 11/18/2008

Child’s Information

• Child’s first name: John
• Middle initial: Smith
• Child’s date of birth: 11/12/2004

Person Filling Out Questionnaire

• First name: Jane
• Middle initial: Q.
• Street address: 123 Center Street, Apt. 9
• Child ID #: 00123456789000000

Program Information

• Program ID #: 98765432123456789
• Program name: Anytown Preschool
• ZIP/Postal code: 21230
• Home telephone number: 410-555-0155
• Other telephone number: 410-555-0189

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. Does your child name at least three items from a common category?
   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”?

   • Response: Yes (10)

2. Does your child answer the following questions?
   “What do you do when you are hungry?”

   • Response: Eat
     “What do you do when you are tired?”
   • Response: Go night-night
   • Score: 5

3. Does your child tell you at least two things about common objects?
   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”?

   • Score: 5

4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”?
   Example: Does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”?

   • Score: 0

GROSS MOTOR

1. Does your child catch a large ball with both hands?

   • Score: 0

2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?

   • Score: 5

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

   • Score: 10

4. Does your child jump forward a distance of 20 inches from a standing position?

   • Score: 5

FINE MOTOR

1. Does your child put together a five- to seven-piece interlocking puzzle?

   • Score: 5

2. Using child-safe scissors, does your child cut a paper in half?

   • Score: 5

3. Does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen?

   • Score: 5

PROBLEM SOLVING

1. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order?
   • Score: 10

PERSONAL-SOCIAL

1. Does your child serve herself using utensils?

   • Score: 5

2. Does your child tell you at least four of the following?

   • First name
   • Last name
   • Age
   • City she lives in
   • Score: 5

Overall Comments

• Had severe ear infections. Didn’t start talking until age 2-3 years, after tubes were placed.
• Concerns about language development. No letter or number recognition at age 4.

Month ASQ-3 Information Summary

• Child's name: John X. Smith
• Date ASQ completed: 11/18/2008
• Child's ID #: 00123456789000000
• Date of birth: 11/12/2004
• Administering program/provider: Anytown Preschool/Ms. Jenkins

Area Score Summary