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 Age	English	Spanish
1 month 0 days through 2 month 30 days	2 month	2 month
3 months 0 days through 4 months 30 days	4 month	4 month
5 months 0 days through 6 months 30 days	6 month	6 month
7 months 0 days through 8 months 30 days	8 month	8 month
9 months 0 days through 9 months 30 days	9 or 10 month	9 or 10 month
10 months 0 days through 10 months 30 days	10 month	10 month
11 months 0 days through 12 months 30 days	12 month	12 month
13 months 0 days through 14 months 30 days	14 month	14 month
15 months 0 days through 16 months 30 days	16 month	16 month
17 months 0 days through 18 months 30 days	18 month + M-CHAT	18 month + M-CHAT
19 months 0 days through 20 months 30 days	20 month	20 month
21 months 0 days through 22 months 30 days	22 month	22 month
23 months 0 days through 25 months 15 days	24 month + M-CHAT	24 month + M-CHAT
25 months 16 days through 28 months 15 days	27 month	27 month
28 months 16 days through 31 months 15 days	30 month	30 month
31 months 16 days through 34 months 15 days	33 month	33 month
34 months 16 days through 38 months 30 days	36 month	36 month
39 months 0 days through 44 months 30 days	42 month	42 month
45 months 0 days through 50 months 30 days	48 month	48 month
51 months 0 days through 56 months 30 days	54 month	54 month
57 months 0 days through 66 months 0 days	60 month	60 month