Ages & Stages

Questionnaires

60 Month Questionnaire
57 months 0 days through 66 months 0 days

Please provide the following information. Use black or blue ink only and print
legibly when completing this form.

Date ASQ completed:

Childs information

Middle
Childs first name: initial: Childs last name:
Childs gender:
Male Female
Childs date of birth:

Person filling out questionnaire

Middle
First name: initial: Last name:
Relationship to child:
Parent Guardian Teacher Child care
provider
Street address: Grandparent Foster
or other parent Other:
relative

State/ ZIP/
City: Province: Postal code:

Home Other
telephone telephone
Country: number: number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information

Child ID #:

Program ID #:

Program name:

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
P101600100 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire 57 months 0 days
through 66 months 0 days
On the following pages are questions about activities babies may do. Your baby may have already done some of the activities
described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indi-
cates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember: Notes:

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.
____________________________________________
Please return this questionnaire by _______________.
____________________________________________

COMMUNICATION YES SOMETIMES NOT YET

1. Without your giving help by pointing or repeating directions, does your

child follow three directions that are unrelated to one another? Give all
three directions before your child starts. For example, you may ask your
child, Clap your hands, walk to the door, and sit down, or Give me
the pen, open the book, and stand up.

2. Does your child use four- and five-word sentences? For example, does
your child say, I want the car? Please write an example:

3. When talking about something that already happened, does your child
use words that end in -ed, such as walked, jumped, or played?
Ask your child questions, such as How did you get to the store? (We
walked.) What did you do at your friends house? (We played.)
Please write an example:

4. Does your child use comparison words, such as heavier, stronger,

or shorter? Ask your child questions, such as A car is big, but a bus
is _____ (bigger); A cat is heavy, but a man is _____ (heavier); A TV
is small, but a book is _____ (smaller). Please write an example:

page 2 of 8
Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600200 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 3 of 8

COMMUNICATION (continued) YES SOMETIMES NOT YET

5. Does your child answer the following questions? (Mark sometimes if

your child answers only one question.)
What do you do when you are hungry? (Acceptable answers include
get food, eat, ask for something to eat, and have a snack.)
Please write your childs response:

What do you do when you are tired? (Acceptable answers include:

take a nap, rest, go to sleep, go to bed, lie down, and sit
down.) Please write your childs response:

6. Does your child repeat the sentences shown below back to you, with-
out any mistakes? (Read the sentences one at a time. You may repeat
each sentence one time. Mark yes if your child repeats both sen-
tences without mistakes or sometimes if your child repeats one sen-
tence without mistakes.)
Jane hides her shoes for Maria to find.
Al read the blue book under his bed. COMMUNICATION TOTAL

GROSS MOTOR YES SOMETIMES NOT YET

1. While standing, does your child throw a ball overhand in the

direction of a person standing at least 6 feet away? To throw
overhand, your child must raise his arm to shoulder height
and throw the ball forward. (Dropping the ball or throwing
the ball underhand should be scored as not yet.)

2. Does your child catch a large ball with both hands? (You
should stand about 5 feet away and give your child two or
three tries before you mark the answer.)

3. Without holding onto anything, does your child stand on

one foot for at least 5 seconds without losing her balance
and putting her foot down? (You may give your child two
or three tries before you mark the answer.)

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600300 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 4 of 8

GROSS MOTOR (continued) YES SOMETIMES NOT YET

4. Does your child walk on his tiptoes for 15 feet (about the length of a
large car)? (You may show him how to do this.)

5. Does your child hop forward on one foot for a distance of 46 feet
without putting down the other foot? (You may give him two tries on
each foot. Mark sometimes if she can hop on one foot only.)

6. Does your child skip using alternating feet? (You may show him how to
do this.)

GROSS MOTOR TOTAL

FINE MOTOR YES SOMETIMES NOT YET

1. Ask your child to trace on the line below with a pencil. Does your child
trace on the line without going off the line more than two times? (Mark
sometimes if your child goes off the line three times.)

2. Ask your child to draw a picture of a person on a blank sheet of paper.

You may ask your child, Draw a picture of a girl or a boy. If your child
draws a person with head, body, arms, and legs, mark yes. If your
child draws a person with only three parts (head, body, arms, or legs),
mark sometimes. If your child draws a person with two or fewer parts
(head, body, arms, or legs), mark not yet. Be sure to include the
sheet of paper with your childs drawing with this questionnaire.

3. Draw a line across a piece of paper. Using child-safe

scissors, does your child cut the paper in half on a
more or less straight line, making the blades go up and
down? (Carefully watch your childs use of scissors for
safety reasons.)

4. Using the shapes below to look at, does your child copy the shapes in
the space below without tracing? (Your childs drawings should look
similar to the design of the shapes below, but they may be different in
size. Mark yes if she copies all three shapes; mark sometimes if
your child copies two shapes.)

(Space for childs shapes)

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600400 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 5 of 8

FINE MOTOR (continued) YES SOMETIMES NOT YET

5. Using the letters below to look at, does your child copy the letters
without tracing? Cover up all of the letters except the letter being
copied. (Mark yes if your child copies four of the letters and you can
read them. Mark sometimes if your child copies two or three letters
and you can read them.)

V H T C A
(Space for childs letters)

6. Print your childs first name. Can your child copy the letters? The letters
may be large, backward, or reversed. (Mark sometimes if your child
copies about half of the letters.)

(Space for adults printing)

(Space for childs printing)

FINE MOTOR TOTAL

PROBLEM SOLVING YES SOMETIMES NOT YET

1. When asked, Which circle is smallest? does your child point to the
smallest circle? (Ask this question without providing help by pointing,
gesturing, or looking at the smallest circle.)

2. When shown objects and asked, What color is this? does your child
name five different colors like red, blue, yellow, orange, black, white, or
pink? (Mark yes only if your child answers the question correctly
using five colors.)

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600500 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 6 of 8

PROBLEM SOLVING (continued) YES SOMETIMES NOT YET

3. Does your child count up to 15 without making mistakes? If so,

mark yes. If your child counts to 12 without making mistakes, mark
sometimes.

4. Does your child finish the following sentences using a word that means
the opposite of the word that is italicized? For example: A rock is
hard, and a pillow is soft.

Please write your childs responses below:

A cow is big, and a mouse is

Ice is cold, and fire is

We see stars at night, and we see the sun during the

When I throw the ball up, it comes

(Mark yes if he finishes three of four sentences correctly. Mark

sometimes if he finishes two of four sentences correctly.)

5. Does your child know the names of numbers? (Mark yes if she identi-
fies the three numbers below. Mark sometimes if she identifies two
numbers.)

3 1 2
6. Does your child name at least four letters in her name? Point to the let-
ters and ask, What letter is this? (Point to the letters out of order.)

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL YES SOMETIMES NOT YET

1. Can your child serve himself, taking food from one container to an-
other, using utensils? For example, does your child use a large spoon to
scoop applesauce from a jar into a bowl?

2. Does your child wash her hands and face using soap and water and dry
off with a towel without help?

3. Does your child tell you at least four of the following? Please mark the
items your child knows.

a. First name d. Last name

b. Age e. Boy or girl

c. City he lives in f. Telephone number

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600600 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 7 of 8

PERSONAL-SOCIAL (continued) YES SOMETIMES NOT YET

4. Does your child dress and undress himself, including buttoning

medium-size buttons and zipping front zippers?

5. Does your child use the toilet by herself? (She goes to the bathroom,
sits on the toilet, wipes, and flushes.) Mark yes even if she does this
after you remind her.

6. Does your child usually take turns and share with other children?

PERSONAL-SOCIAL TOTAL

OVERALL
Parents and providers may use the space below for additional comments.

1. Do you think your child hears well? If no, explain: YES NO

2. Do you think your child talks like other children her age? If no, explain: YES NO

3. Can you understand most of what your child says? If no, explain: YES NO

4. Can other people understand most of what your child says? If no, explain: YES NO

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600700 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month Questionnaire page 8 of 8

OVERALL (continued)

5. Do you think your child walks, runs, and climbs like other children his age? YES NO
If no, explain:

6. Does either parent have a family history of childhood deafness or hearing YES NO
impairment? If yes, explain:

7. Do you have any concerns about your childs vision? If yes, explain: YES NO

8. Has your child had any medical problems in the last several months? If yes, explain: YES NO

9. Do you have any concerns about your childs behavior? If yes, explain: YES NO

10. Does anything about your child worry you? If yes, explain: YES NO

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
E101600800 2009 Paul H. Brookes Publishing Co. All rights reserved.
 60 Month ASQ-3 Information Summary 57 months 0 days through
66 months 0 days

Childs name: ________________________________________________________ Date ASQ completed: __________________________________________

Childs ID #: ______________________________________________________ Date of birth: ______________________________________________

Administering program/provider:

1. SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 Users Guide for details, including how to adjust scores if item
responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total.
In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.
Total
Area Cutoff Score 0 5 10 15 20 25 30 35 40 45 50 55 60
Communication 33.19
Gross Motor 31.28
Fine Motor 26.54
Problem Solving 29.99
Personal-Social 39.07

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 Users Guide, Chapter 6.

1. Hears well? Yes NO 6. Family history of hearing impairment? YES No

Comments: Comments:

2. Talks like other children his age? Yes NO 7. Concerns about vision? YES No
Comments: Comments:

3. Understand most of what your child says? Yes NO 8. Any medical problems? YES No
Comments: Comments:

4. Others understand most of what your child says? Yes NO 9. Concerns about behavior? YES No
Comments: Comments:

5. Walks, runs, and climbs like other children? Yes NO 10. Other concerns? YES No
Comments: Comments:

3. ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall
responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
If the childs total score is in the area, it is above the cutoff, and the childs development appears to be on schedule.
If the childs total score is in the area, it is close to the cutoff. Provide learning activities and monitor.
If the childs total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply. 5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
______ Provide activities and rescreen in _____ months.
X = response missing).
______ Share results with primary health care provider.
1 2 3 4 5 6
______ Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
Communication
______ Refer to primary health care provider or other community agency (specify
Gross Motor
reason): __________________________________________________________.
Fine Motor
______ Refer to early intervention/early childhood special education.
Problem Solving
______ No further action taken at this time
Personal-Social
______ Other (specify): ____________________________________________________

Ages & Stages Questionnaires, Third Edition (ASQ-3), Squires & Bricker
P101600900 2009 Paul H. Brookes Publishing Co. All rights reserved.