ASQ 4 years
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
Back
Next
Communication Section
Does your child name at least three items from a common category? For example, if you say to your child, “Tell me some things that you can eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like “cow, dog, and elephant”?
*
Yes
Sometimes
Not yet
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.”)
*
Yes
Sometimes
Not yet
Please write your child’s 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.”)
*
Yes
Sometimes
Not yet
Please write your child’s response:
Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” do they say something like, “It’s round. I throw it. It’s big”?
*
Yes
Sometimes
Not yet
Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”?
*
Yes
Sometimes
Not yet
Without you giving help by pointing or repeating, 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.”
*
Yes
Sometimes
Not yet
Does your child use all of the words in a sentence (for example, “a,”“the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?”
*
Yes
Sometimes
Not yet
Score For Communication Section
Back
Next
Gross Motor
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.)
*
Yes
Sometimes
Not yet
Does your child climb the rungs of a ladder of a playground slide and slide down without help?
*
Yes
Sometimes
Not yet
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.”)
*
Yes
Sometimes
Not yet
Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?
*
Yes
Sometimes
Not yet
Does your child jump forward a distance of 20 inches from a standing position, starting with their feet together?
*
Yes
Sometimes
Not yet
Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing their balance and putting their foot down? (You may give your child two or three tries before you mark the answer.)
*
Yes
Sometimes
Not yet
Score For Gross Motor Section
Back
Next
Fine Motor
Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)
*
Yes
Sometimes
Not yet
Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.)
*
Yes
Sometimes
Not yet
Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with-out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)
*
Yes
Sometimes
Not yet
Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.)
*
Yes
Sometimes
Not yet
Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?
*
Yes
Sometimes
Not yet
Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)
*
Yes
Sometimes
Not yet
Score for Fine Motor section
Back
Next
Problem Solving
When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If necessary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers to answer “yes” to this question.)
*
Yes
Sometimes
Not yet
When asked, “Which circle is the smallest?” does your child point tothe smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)
*
Yes
Sometimes
Not yet
Without your giving help by pointing, does your child follow three different directions using the words “under,” “between,” and “middle”? For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.”
*
Yes
Sometimes
Not yet
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.)
*
Yes
Sometimes
Not yet
Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.
*
Yes
Sometimes
Not yet
If you place five objects in front of your child, can they count them by saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.)
*
Yes
Sometimes
Not yet
Score for Problem Solving Section
Back
Next
Personal-Social
Does your child serve themself, taking food from one container to another using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?
*
Yes
Sometimes
Not yet
Does your child tell you at least four of the following? Please mark the items your child knows.
First name
Age
City they live in
Last Name
Boy or Girl
Telephone Number
Does your child wash his hands using soap and water and dry off with a towel without help?
*
Yes
Sometimes
Not yet
Does your child tell you the names of two or more playmates, not including brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)
*
Yes
Sometimes
Not yet
Does your child brush her teeth by putting toothpaste on the toothbrush and brushing all of their teeth without help? (You may still need to check and rebrush your child’s teeth.)
*
Yes
Sometimes
Not yet
Does your child dress or undress themself without help (except for snaps, buttons, and zippers)?
*
Yes
Sometimes
Not yet
Score for Personal-Social section
Back
Next
Overall
Do you think your child hears well?
If yes, leave blank. If no, explain.
Do you think your child talks like other children their age? If no, explain:
If yes, leave blank. If no, explain.
Do you think your child walks, runs, and climbs like other toddlers their age? If no, 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 yes, leave blank. If no, explain.
Can you understand most of what your child says?
If yes, leave blank. If no, explain.
Can other people understand most of what your child says? If no, explain:
If no, leave blank. If yes, explain.
Do you have concerns about your child’s vision?
If no, leave blank. If yes, explain.
Has your child had any medical problems in the last several months?
If no, leave blank. If yes, explain.
Do you have any concerns about your child's behavior?
If no, leave blank. If yes, explain.
Does anything about your child worry you?
If no, leave blank. If yes, explain.
Submit
Should be Empty: