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 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 |