# 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

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### 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  
| YES | SOMETIMES | NOT YET |  |
| --- | --- | --- | --- |
| ○ | ○ | ● | 0 |
| ○ | ● | ○ | 5 |

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
| Area             | Cutoff | Total Score | 0 | 5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 |
|------------------|--------|-------------|---|---|----|----|----|----|----|----|----|----|----|----|----|
| Communication     | 30.72  | 25          |   |   |    |    |    |    |    |    |    |    |    |    |    |
| Gross Motor       | 32.78  | 60          |   |   |    |    |    |    |    |    |    |    |    |    |    |
| Fine Motor        | 15.81  | 20          |   |   |    |    |    |    |    |    |    |    |    |    |    |
| Problem Solving   | 31.30  | 20          |   |   |    |    |    |    |    |    |    |    |    |    |    |
| Personal-Social   | 26.60  | 60          |   |   |    |    |    |    |    |    |    |    |    |    |    |