ASQ 5 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
Without you 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.”
*
Yes
Sometimes
Not yet
Does your child use four- and five-word sentences? For example, does your child say, “I want the car”?
*
Yes
Sometimes
Not yet
Please write an example:
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 friend’s house?” (“We played.”)
*
Yes
Sometimes
Not yet
Please write an example:
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).
*
Yes
Sometimes
Not yet
Please write an example:
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 repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark “yes” if your child repeats both sentences without mistakes or “sometimes” if your child repeats one sentence without mistakes.) : Jane hides her shoes for Maria to find. Al read the blue book under his bed.
*
Yes
Sometimes
Not yet
Score For Communication Section
Back
Next
Gross Motor
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 their 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 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
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
Does your child walk on their tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)
*
Yes
Sometimes
Not yet
Does your child hop forward on one foot for a distance of 4–6 feet without putting down the other foot? (You may give them two tries on each foot. Mark “sometimes” if they can hop on one foot only.)
*
Yes
Sometimes
Not yet
Does your child skip using alternating feet? (You may show them how to do this.)
*
Yes
Sometimes
Not yet
Score For Gross Motor Section
Back
Next
Fine Motor
Draw a straight line then ask your child to trace on the line 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.)
*
Yes
Sometimes
Not yet
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.”
*
Yes
Sometimes
Not yet
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 child’s use of scissors for safety reasons.)
*
Yes
Sometimes
Not yet
Using the shapes below to look at, can your child copy the shapes without tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different insize. Mark “yes” if they copy all three shapes; mark “sometimes” if your child copies two shapes.)
*
Yes
Sometimes
Not yet
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.)
*
Yes
Sometimes
Not yet
Print your child’s 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.)
*
Yes
Sometimes
Not yet
Score for Fine Motor section
Back
Next
Problem Solving
When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)
*
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 count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “sometimes.”
*
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
Does your child finish the following sentences using a word that means the opposite? For example: “A rock is hard, and a pillow is soft.” (Mark “yes” if they finish three of four sentences correctly. Mark “sometimes” if they finish two of four sentences correctly.)
*
Yes
Sometimes
Not yet
Does your child finish the following sentences using a word that means the opposite of the first word? For example: “A rock is hard, and a pillow is soft.” Please write your child’s 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
Does your child know the names of numbers? (Mark “yes” if they identify the three numbers below. Mark “sometimes” if they identify two numbers.)
*
Yes
Sometimes
Not yet
Does your child name at least four letters in their name? Point to the letters and ask, “What letter is this?” (Point to the letters out of order.)
*
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 wash their hands using soap and water and dry off with a towel without help?
*
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 dress and undress themself, including buttoning medium-size buttons and zipping front zippers?
*
Yes
Sometimes
Not yet
Does your child use the toilet by themself? (They go to the bathroom, sit on the toilet, wipe, and flush.) Mark “yes” even if they do this after you remind them.
*
Yes
Sometimes
Not yet
Does your child usually take turns and share with other children?
*
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: