ASQ 4 months
Child's Name
*
First Name
Last Name
Parent/Guardian filling out form
*
First Name
Last Name
Email
*
example@example.com
Child's Birthday
*
/
Month
/
Day
Year
Date
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Communication Section
Does your baby chuckle softly?
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Sometimes
Yes
Not yet
After you have been out of sight, does your baby smile or get excited when they see you?
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Yes
Sometimes
Not yet
Does your baby stop crying when they hear a voice other than yours?
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Yes
Sometimes
Not yet
Does your baby make high-pitched squeals?
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Yes
Sometimes
Not yet
Does your baby laugh?
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Yes
Sometimes
Not yet
Does your baby make sounds when looking at toys or people?
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Yes
Sometimes
Not yet
Score For Communication Section
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Gross Motor
While your baby is on their back, do they move their head from side to side?
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Yes
Sometimes
Not yet
After holding their head up while on their tummy, does your baby lay their head back down on the floor, rather than let it drop or fall forward?
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Yes
Sometimes
Not yet
When your baby is on their tummy, do they hold their head up so that their chin is about 3 inches from the floor for at least 15 seconds?
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Yes
Sometimes
Not yet
When your baby is on their tummy, do they hold their head straight up, looking around? (They can rest on their arms while doing this.)
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Yes
Sometimes
Not yet
When you hold them in a sitting position, does your baby hold their head steady?
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Yes
Sometimes
Not yet
While your baby is on their back, does your baby bring their hands together over their chest, touching their fingers?
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Yes
Sometimes
Not yet
Score For Gross Motor Section
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Fine Motor
Does your baby hold their hands open or partly open (rather than in fists, as they did when they were a newborn)?
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Yes
Sometimes
Not yet
When you put a toy in their hand, does your baby wave it about, at least briefly?
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Yes
Not yet
Does your baby grab or scratch at their clothes?
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Yes
Sometimes
Not yet
When you put a toy in their hand, does your baby hold onto it for about 1 minute while looking at it, waving it about, or trying to chew it?
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Yes
Sometimes
Not yet
Does your baby grab or scratch their fingers on a surface in front of them, either while being held in a sitting position or when they are on their tummy?
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Yes
Sometimes
Not yet
When you hold your baby in a sitting position, do they reach for a toy on a table close by, even though their hand may not touch it?
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Yes
Sometimes
Not yet
Score for Fine Motor section
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Problem Solving
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 their eyes, sometimes turning their head?
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Yes
Sometimes
Not yet
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 their eyes?
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Yes
Sometimes
Not yet
When you hold your baby in a sitting position, do they look at a toy (about the size of a cup or rattle) that you place on the table or floor in front of them?
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Yes
Sometimes
Not yet
When you put a toy in their hand, does your baby look at it?
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Yes
Sometimes
Not yet
When you put a toy in their hand, does your baby put the toy in their mouth?
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Yes
Sometimes
Not yet
When you dangle a toy above your baby while they are lying on their back, does your baby wave their arms toward the toy?
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Yes
Sometimes
Not yet
Score for Problem Solving Section
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Personal-Social
Does your baby watch their hands?
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Yes
Sometimes
Not yet
When your baby has their hands together, do they play with their fingers?
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Yes
Sometimes
Not yet
When your baby sees the breast or bottle, do they seem to know they are about to be fed?
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Yes
Sometimes
Not yet
Does your baby help hold the bottle with both hands at once, or when nursing, do they hold the breast with their free hand?
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Yes
Sometimes
Not yet
Before you smile or talk to your baby, do they smile when they see you nearby?
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Yes
Sometimes
Not yet
When in front of a large mirror, does your baby smile or coo at themself?
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Yes
Sometimes
Not yet
Score for Personal-Social section
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Overall
Does your baby use both hands and both legs equally well? If no, explain:
If yes, leave blank. If no, explain.
When you help your baby stand, are their feet flat on the surface most of the time? If no, explain:
If yes, leave blank. If no, explain.
Do you have concerns that your baby is too quiet or does not make sounds like other babies? If yes, explain:
If yes, leave blank. If no, explain.
Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:
If no, leave blank. If yes, explain.
Do you have concerns about your baby’s vision? If yes, explain:
If no, leave blank. If yes, explain.
Has your baby had any medical problems in the last several months? If yes, explain:
If no, leave blank. If yes, explain.
Do you have any concerns about your baby’s behavior? If yes, explain:
If no, leave blank. If yes, explain.
Does anything about your baby worry you? If yes, explain:
If no, leave blank. If yes, explain.
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