ASQ-3 (4 Months) DOWNLOAD PDF ASQ-3 (4 Months) ASQ-3(4 Months) Date ASQ completed:Baby’s informationBaby’s first name:Middle initial:Baby’s last name:Baby’s date of birth:If baby was born 3 or more weeks prematurely, # of weeks premature:Baby’s gender:MaleFemalePerson filling out questionnaireFirst name:Middle initialLast name:Street address:Relationship to baby:ParentGuardianTeacherChild care providerGrandparent or other relativeFoster parentOther:City:State/Province:ZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweHome telephone number:Other telephone number:E-mail address:Names of people assisting in questionnaire completion:PROGRAM INFORMATIONBaby ID #:Age at administration, in month and days:Program ID #:If premature, adjust age, in month and days:Program name:Important Points to Remember:Try each activity with your baby before marking a response.Make completing this questionnaire a game that is fun for you and your baby.Make sure your baby is rested and fed.Please return this questionnaire byCOMMUNICATION1. Does your baby make high-pitched squeals?YESSOMETIMESNOT YET2. After you have been out of sight, does your baby smile or get excited when he sees you?YESSOMETIMESNOT YET3. Does your baby stop crying when she hears a voice other than yours?YESSOMETIMESNOT YET4. Does your baby make high-pitched squeals?YESSOMETIMESNOT YET5. Does your baby laugh?YESSOMETIMESNOT YET6. Does your baby make sounds when looking at toys or people?YESSOMETIMESNOT YETGROSS MOTOR1. While your baby is on his back, does he move his head from side to side?YESSOMETIMESNOT YET2. After holding her head up while on her tummy, does your baby lay her head back down on the floor, rather than let it drop or fall forward?YESSOMETIMESNOT YET3. When your baby is on his tummy, does he hold his head up so that his chin is about 3 inches from the floor for at least 15 seconds?YESSOMETIMESNOT YET4. When your baby is on her tummy, does she hold her head straight up, looking around? (She can rest on her arms while doing this.)YESSOMETIMESNOT YET5. When you hold him in a sitting position, does your baby hold his head steady?YESSOMETIMESNOT YET6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?YESSOMETIMESNOT YETFINE MOTOR1. Does your baby hold his hands open or partly open (rather than in fists, as they were when he was a newborn)?YESSOMETIMESNOT YET2. When you put a toy in her hand, does your baby wave it about, at least briefly?YESSOMETIMESNOT YET3. Does your baby grab or scratch at his clothes?YESSOMETIMESNOT YET4. When you put a toy in her hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?YESSOMETIMESNOT YET5. Does your baby grab or scratch his fingers on a surface in front of him, either while being held in a sitting position or when he is on his tummy?YESSOMETIMESNOT YET6. When you hold your baby in a sitting position, does she reach for a toy on a table close by, even though her hand may not touch it?YESSOMETIMESNOT YETPROBLEM SOLVING1. When you move a toy slowly from side to side in front of your baby’s face (about 10 inches away), does your baby follow the toy with his eyes, sometimes turning his head?YESSOMETIMESNOT YET2. When you move a small toy up and down slowly in front of your baby’s face (about 10 inches away), does your baby follow the toy with her eyes?YESSOMETIMESNOT YET3. When you hold your baby in a sitting position, does he look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of him?YESSOMETIMESNOT YET4. When you put a toy in her hand, does your baby look at it?YESSOMETIMESNOT YET5. When you put a toy in his hand, does your baby put the toy in his mouth?YESSOMETIMESNOT YET6. When you dangle a toy above your baby while she is lying on her back, does your baby wave her arms toward the toy?YESSOMETIMESNOT YETPERSONAL-SOCIAL1. Does your baby watch his hands?YESSOMETIMESNOT YET2. When your baby has her hands together, does she play with her fingers?YESSOMETIMESNOT YET3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?YESSOMETIMESNOT YET4. Does your baby help hold the bottle with both hands at once, or when nursing, does she hold the breast with her free hand?YESSOMETIMESNOT YET5. Before you smile or talk to your baby, does he smile when he sees you nearby?YESSOMETIMESNOT YET6. When in front of a large mirror, does your baby smile or coo at herself?YESSOMETIMESNOT YETOVERALLParents and providers may use the space below for additional comments1. Does your baby use both hands and both legs equally well? If no, explain:SOMETIMESNOT YET2. When you help your baby stand, are his feet flat on the surface most of the time? If no, explain:SOMETIMESNOT YET3. Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:SOMETIMESNOT YET4. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:SOMETIMESNOT YET5. Do you have concerns about your baby’s vision? If yes, explain:SOMETIMESNOT YET6. Has your baby had any medical problems in the last several months? If yes, explain:SOMETIMESNOT YET7. Do you have any concerns about your baby’s behavior? If yes, explain:SOMETIMESNOT YET8. Does anything about your baby worry you? If yes, explain:SOMETIMESNOT YETAges & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker © 2009 Paul H. Brookes Publishing Co. All rights reserved.Submit form
