Ages & Stages Questionnaires (ASQ) – New Patients

All new patients through 60 months of age are required to complete Ages & Stages Questionnaire (ASQ-3). Please print and complete age appropriate forms, available below for your convenience. All scoring will be done for you at the office, at time of visit.

Please note that patients in 18 months and 24 months age groups will also need to complete M-Chat questionnaire, link to which can be found next to the corresponding ASQ-3 form.

Kindly keep in mind that age of premature babies up to 24 months counts differently. To avoid confusion, and for your convenience, please use this quick ASQ Age Calculator to ensure correct ASQ-3 questionnaire is chosen for your child’s age.

Printable Questionnaire Forms

Child's AgeEnglishSpanish
1 month 0 days through 2 month 30 days2 month2 month
3 months 0 days through 4 months 30 days4 month4 month
5 months 0 days through 6 months 30 days6 month6 month
7 months 0 days through 8 months 30 days8 month8 month
9 months 0 days through 9 months 30 days9 or 10 month9 or 10 month
10 months 0 days through 10 months 30 days10 month10 month
11 months 0 days through 12 months 30 days12 month12 month
13 months 0 days through 14 months 30 days14 month14 month
15 months 0 days through 16 months 30 days16 month16 month
17 months 0 days through 18 months 30 days18 month + M-CHAT18 month + M-CHAT
19 months 0 days through 20 months 30 days20 month20 month
21 months 0 days through 22 months 30 days22 month22 month
23 months 0 days through 25 months 15 days24 month + M-CHAT24 month + M-CHAT
25 months 16 days through 28 months 15 days27 month27 month
28 months 16 days through 31 months 15 days30 month30 month
31 months 16 days through 34 months 15 days33 month33 month
34 months 16 days through 38 months 30 days36 month36 month
39 months 0 days through 44 months 30 days42 month42 month
45 months 0 days through 50 months 30 days48 month48 month
51 months 0 days through 56 months 30 days54 month54 month
57 months 0 days through 66 months 0 days60 month60 month