‘Ages & Stages Questionnaires’: A Parent-Completed, Child Monitoring System Second Edition By Diane Bricker and Jane Squires with assistance from Linda Mounts, LaWanda Potter, Robert Nickel, Elizabeth Twombly, and Jane Farrell Copyright © 1980 by Paul H, Brookes Pubishing Co, 48 Month + 4. Year Questionnaire On the following pages are questions about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet. Important Points to Remember: Be sure to try each activity with your child before checking @ box. Try to make completing this questionnaire a game that is fun for you and your child Make sure your child is rested, fed, and ready to play. Ifyou have any questions or concerns about your child or about this questionnaire, please call: 4 a a “Please return this questionnaire by a 4 Look forward to filing out another questionnaire in ____—_. months. eASQ‘Ages & Stages Questionnaires’ A Parent-Completed, Child-Monitoring System ‘Second Edition By Diane Bricker and Jane Squires wth assistance {rom Linda Mounts, LaWanda Petter, Robert Nickel, Elizabeth Twombly, and Jane Ferrell CCopytight © 1900 by Paul H, Brookes Publishing Co, 48 Month + 4 Year Questionnaire Please provide the following information. Child's name: — Chile's date of birth; ——________— Today's date: Person filing out this questionnaire: —______—— What is your relationship to the child? — Your telephone: Boe Eee a Your mailing address: ——_______—— city: a State: List paople assisting in questionnaire completion: ‘Administering program or provider: ———————_—_$_—__—___—_————YES SOMETIMES NOT YET COMMUNICATION Be sure to try each activity with your child, 4. Doos your child name at least three itsms from a common category? For example, if you say to your child “Tell me some things that you ‘an eat does Your child anwer with something tke, “Cookies, e998 Gand cereal"? Ori you sey, "Tall me the names of some animals’ doss ‘Your child answer with something like, “Gow, dog, and elephant”? Q Qa Q 2, Does your child anewer the following questions: what do you do when you are hungry?" (Acceptable answers Include: Get fo08" "Eat “Ask for something o eal,” and “Have a snack’) Please write your child's response: ‘what do you do when you are tired?" (Aceptable answers include: “Take a nap’ Fest” “Go to sleep!’ “Go to bed: "Lie downy and “Sit down") Please write your child's responee: Mark "sometimes' if your child answers only one question. Q Q Q — 3, Does your child tell you atleast two things about common objects? For example, if you say to your chil, "Tall me about your ball’ does he say somathing lke, “its round. | throw It t's big"? Qa Qa Qa ee 44, Does your child use endings of words, such as “sedi” and “ing”? For svample, does your child say things ike, "T see two cats") am playing’ or "i kicked the ball"? Qa a Qa 6. Without giving help by pointing or repeating, does your child follow threo directions that are unrelated to one another? For example, you may ‘ask your child o “Clap your hands, walk to the door, and sit down.” a Q Q 6. Does your child use all of tho words in @ sentence (for example, “thet "am,'sis? and “afe’) to make complete sentences, such as Mam going tothe parc” or “is there a toy to play with?” oF "Are you coming, too?” a Q a essaee COMMUNICATION TOTAL GROSS MOTOR Be sure to try each activi with your chil 41. Does your eld catch a large ball with both hands? You should stand about 5 feet away and give your child two or ‘hos tres, 2, Does your child climb the rungs of a ladder of a playground slide and slide down without help? Q Qa a pee 8, While standing, does your chi throw a ball overfanet in the direction of a person standing at least 6 feet away? i) “To tow overhand, your child must raise her arm to shoulder height and throw the ball fonward, (Dropping the bal, letng the ball go, or throning the ball underhand ‘should be scored as “not yet) Qa a see Snr unas’ Scar nr eps a Se ae s GASQ 12 monns/4 yearsGROSS MOTOR (continued) “4. Does your chid hop up and down on either the right or left foot at least cone time without fosing his balenos or fing? 5. Does your child jamp forward a distance of 20 inches from a standing position, starting with her feet together? 16. Without holding onto anything, does your child stand on ‘one foo! for at least § seconds without losing his balance ‘and pulting his foot down? You may give your chia two for three trlas before you mark the questlon. FINE MOTOR Be suro to try each activity with your chil. 4. Does your child put together a six-piece interlocking puzzle? (I one is rot available, take a lulkpage picture from a magazine or calalog and ut nto six pieces. Does your child put it back together correctly?) A per ao er ‘watch your child's use of scissors for safety He 8. Using the shapes below to look at, does your chid copy at feast three shapes onto a large piace of paper using a pencl or crayon, without tracing? Your childs drawings shouki look sinlar to the design of the shapes below, aut they may be different in size. Li 4. Does your child unbutton one or more buttons? Your child may use his ‘own clothing or a dol’s clothing. 5. Does your chiki draw pictures of people that have atleast three of the following features: head, eyes, nose, mouth, neck, hal, trunk, arms, hands, legs, or feet? 16. Does your child color mostly within the lines in a coloring book? Your child should not go more than "Inch outside the linas on most of the picture. _Agas & Stages Questonnaites, Socond Econ, Briere a GFioog Pa H rose Pasting Co. £0805 a SOMETIMES NOT YET im Qa ot a a ett Qa a GROSS MOTOR TOTAL a Q saint a Q a a Qa i Qa Q a Qa a ae Q a FINE MOTOR TOTAL BASQ 12 monte yearsYES SOMETIMES NOT YET PROBLEM SOLVING Be sure to try each activity with your child 4. When you say, “Say five eight three” does your child tepeat just these three numbers in the correct order? Do nt repeat these numbers. It necessary, tty another series of numbers and say, “Say six nine two!” Your chiid must repeat just one series of three numbers to answer “yes! to this question. a a a Fee 2, When asked, ‘Which ciclo is the smallest?" does your child point tothe smallest circle? Ask this question without providing help by pointing, ‘gesturing, oF looking at the smallest circle. a Qa a '& Without giving help by pointing, does your child folow three dliferent directions using the words “unde, “between.” and “middle”? For ‘example, ask your child to put @ book “under the couch” Then ask hor to put the ball “between tho chalts” and the shoe “in the mide of the table” a Qa Q — 4. When shown an object and asked, “What color is this?” does your child name five diferent colors lke red, blue, yolow, orange, black, sntite, of pink? Answer “yes" only if your child answers the question correctly using tive colors. a a Q ey 5, Does your chiki dress up and “play-act pretending to be someone br something else? For example, your child may dress up indifferent Clothes and pretond to be a mommy, daddy, brother or sister, or an imaginary animal or figure. Q Qa Qa 6. Ifyou place five objects in front of your child, can he count them saying, “One, two, three, four, five in order? Ask this question + without providing help by pointing, gesturing, or naming. a a a PROBLEM SOLVING TOTAL —— PERSONAL-SOCIAL Be sure to try each activity with your cil. 4, Does your child serve herself, taking food from one container to ‘another using utensils? For example, can your child use a large ‘spoon to scoop applesauce from a jar into a bow? a a a — 2. Does your child tell you at least four of the following: a, First name 4, Last name b Age 8, Boy or git! ©, City she tives in 1, Telephone number Please circle the items your child knows. Q Qa a eat 3, Does your child wash his hands and face using soap ani dry off with ‘a towel without help? Q 4 Does your hil tl you the names of we or more playmates, nt a et cirs std aster Ack ts question without prong May by suggesting names of playmates o nds. a Age & Stages Questionnaires’, Second Eaitlon, Bricker etal isi Sed Sat ate coco 5 BASQ 12 montns;4 yearsSOMETIMES NOT YET PERSONAL-SOCIAL —(continuod) 5, Does your child brush her teeth by putting toothpaste on the toothbrush and brushing al her teeth without help? You may stil need to check anc rebrush your child's teeth. a a Qa ‘Does your child dtess or undress himself without help (except for snaps, buttons, and zippers)? Qa Qa Q PERSONAL-SOCIAL TOTAL OVERALL —_Paronts and providers may use the space below or the back of this sheet for ‘additional comments. 4, Do you think your chité hears well? yesQ) Ino, explain au ates 2. Do you think your child talks like other chitdren her age? yes Ino, explain: eset eee 3, Can you understand most of what your child says? vesO) Ino, explain: ae ae 14, Do you think your child walks, runs, and climbs like other children his age? vesO Hn, explain: ae 5, Doss either parent have a family history of childhood deatness or hearing impairment? yes Ht yes, explain: —_____ Bee 6. Do you have any concerns about your childs vieion? yes I yes, explain eee 7, Has your child had any medical problems in the last several months? ves) yes, explain: Spee eteeeeeeeeceee eee 8 Does anything about your child worry you? ves It yes, explain: SESE gegeELESE aE ES L ‘oes & Stages Questonnaes”, Second Eon, Bucher a noQ) noQ noQ noo nog nog noQ) noQ | os a amie : ASQ su montn yor48 Month/4 Year ASQ Information Summary ‘Chile's name: Date of bith: Person filing out the ASO: Relationship to chil Mailing adctess: city: State: ae: Srecceh ag ctr eceeeeeeeeee cee eeeE eee pang Aone Today's date: GYERALL Please transfor the anewors inthe Overall section of the questionnaire by crlng ‘yee or “no” and reporting any cornments, 1. Hears well? YES NO 5. Family history of hearing impairment? Yes NO ‘Comments: ‘Comments: 2, Talks tke other childron? YES NO 6. Vislon concerns? Yes NO Comments: Comments: 8, Understand child? YES NO 7. Racent medical problems? YES NO Comments: Comments: 4, Walka, runs, and climbs lke others? Yes NO 18. Other concerns? Yes NO Comments: ‘Comments: SCORING THE QUESTIONNAIRE ‘L_ Be sute each tem nas beon answered. I antem cannot be answered, refer othe rtlo scoring pracodure in The ASQ Users Guide 2. Score each item on the questionnaire by writing the appropriate number on the line by each iter answer. YeS=10 SOMETIMES =5 NOT YET =0 ‘8, Add up the item scores for each area, and record these totals inthe space provided for area totals Sain wane shi total score for each area by filing inthe appropiate cicleon the chart below. For example, the fetal score for the Communication area was 50, fl in the circle below 60 in the first row, Total Communication {Gross motor Fine motor Problem solving Personal-social o 6 0 1 AO 45 80 60 QO 9 Oo oO 0 oO OO. ° On 9 (ornme) oO oO Total > 5 0 1 2 2% 9 a a ‘Examine the blackened eitclos for each area in the chat above, 15. I the child's total ecore falls within the = atea, the child appears to be doing wel inthis area at this timo. eI the chis tolal eoore falls within the G2 area, talk with a professional. The child may need further evaluation OPTIONAL: The specific answers to each item on the questionnaire can be recorded below on the summary chart cee cam naka eaner rate PO oe < (O1O[O} fOICIO! *(O[OIS| +jOjCiO +{OJO|S) 4 | JOO) 2\OlC'O} 2|OlO|O} 2\O1O\O) 2|O\O/0) eee 32.9) 31010} slOlO[O] s/OlOlO) »|O/O\0 s|O10lO) [2 Fre motor 300| «QQIO| «|COIO) «OlOj|O) + OlO[O} +/O/O!O) 2 problem solving 36.0) sOlO}|O) s|QjO\O siIO1Olo) s[OlO|O! s|O|OlO Berroa [laa] OOO) s[OjOIO} *|O}O|O] +O 2[Ol010} (4) OER SO yew yee vss ‘Administering program or provider: ‘ages & Sages Qucatonnais, Socond Eder, Eker Gea Paul, bootes Pubtahing Ge. / 0308