The Ages & Stages Questionnaires® 54 Month Questionnaire is a tool designed to assess the developmental progress of children aged 51 months to 56 months. This questionnaire helps parents, guardians, and educators understand a child's abilities in various areas, including communication, motor skills, problem-solving, and personal-social skills. Completing this form is crucial for tracking developmental milestones, so be sure to fill it out by clicking the button below.
The Ages & Stages Questionnaires® 54 Month Questionnaire is a vital tool designed for assessing the developmental progress of children between the ages of 51 months and 56 months. This questionnaire aims to gather information regarding a child's communication, gross motor, fine motor, problem-solving, and personal-social skills. Parents, guardians, or caregivers complete the form by marking responses that indicate whether the child performs specific activities regularly, sometimes, or not yet. The questionnaire emphasizes the importance of engaging with the child during this process, encouraging caregivers to make it a fun and interactive experience. Key instructions suggest that caregivers try each activity with the child prior to marking a response, ensuring a more accurate representation of the child's abilities. Additionally, the form collects essential information about the child and the person completing the questionnaire, including names, relationships, and contact details, which aids in the organization and follow-up of developmental assessments. The structured format of the questionnaire allows for easy navigation, with sections dedicated to various developmental domains, providing a comprehensive overview of the child's progress at this critical stage of growth.
Ages & Stages
Questionnaires®
54 51 months 0 days through 56 months 30 days
Month Questionnaire
Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Date ASQ completed:
Child’s information
Middle
Child’s first name:
initial:
Child’s last name:
Child’s gender:
Male
Female
Child’s date of birth:
Person filling out questionnaire
Last name:
First name:
Relationship to child:
Parent
Guardian
Teacher
Child care
provider
Street address:
Grandparent
Foster
Other:
or other
parent
relative
State/
ZIP/
City:
Province:
Postal code:
Home
Other
telephone
Country:
number:
E-mail address:
Names of people assisting in questionnaire completion:
Program Information
Child ID #:
Program ID #:
Program name:
P101540100
Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
54 Month Questionnaire
51 months 0 days
through 56 months 30 days
On the following pages are questions about activities children may do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet. For each item, please fill in the circle that indicates whether your child is doing the activity regularly, sometimes, or not yet.
Important Points to Remember:
✓
❑ Try each activity with your child 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 _______________.
Notes:
____________________________________________
COMMUNICATION
YES
SOMETIMES
NOT YET
1. Does your child tell you at least two things about common objects? For example, if you say to your child, ÒTell me about your ball,Ó does she say something like, ÒItÕs round. I throw it. ItÕs bigÓ?
2. Does your child use all of the words in a sentence (for example, Òa,Ó Òthe,Ó Òam,Ó Òis,Ó and ÒareÓ) to make complete sentences, such as ÒI am going to the park,Ó ÒIs there a toy to play with?Ó or ÒAre you com- ing, too?Ó
3. Does your child use endings of words, such as Ò-s,Ó Ò-ed,Ó and Ò-ingÓ? For example, does your child say things like, ÒI see two cats,Ó ÒI am playing,Ó or ÒI kicked the ballÓ?
4. Without giving your child help by pointing or repeating directions, does he follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, ÒClap your hands, walk to the door, and sit down,Ó or ÒGive me the pen, open the book, and stand up.Ó
5. Does your child use four- and five-word sentences? For example, does your child say, ÒI want the carÓ? Please write an example:
6. When talking about something that already happened, does your child use words that end in Ò-ed,Ó such as Òwalked,Ó Òjumped,Ó or ÒplayedÓ? Ask your child questions, such as ÒHow did you get to the store?Ó (ÒWe walked.Ó) ÒWhat did you do at your friendÕs house?Ó (ÒWe played.Ó)
Please write an example:
COMMUNICATION TOTAL
page 2 of 7
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Ages & Stages Questionnaires¨, Third Edition (ASQ-3ª), Squires & Bricker
54 Month Questionnaire page 3 of 7
GROSS MOTOR
1. Does your child hop up and down on either the right foot or the left foot at least one time without losing her balance or falling?
2. 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.”)
3. Does your child jump forward a distance of 20 inches from a standing position, starting with her feet together?
4. 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.)
5. 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.)
6. 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.)
GROSS MOTOR TOTAL
FINE MOTOR
1.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.)
2.Does your child unbutton one or more buttons? Your child may use his own clothing or a doll’s clothing.
3.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.)
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54 Month Questionnaire page 4 of 7
FINE MOTOR (continued)
SOMETIMESNOT YET
4. 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.)
5. 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 child’s drawing with this questionnaire.
6. 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.)
FINE MOTOR TOTAL
PROBLEM SOLVING
1. 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.)
2. 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, sister, or an imag- inary animal or figure.
3. If you place five objects in front of your child, can she count them by saying, “One, two, three, four, five” in order? (Ask this question WITHOUT providing help by pointing, gesturing, or naming.)
4. 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.)
5. Does your child count up to 15 without making mistakes? If so, mark “yes.” If your child counts to 12 without making mistakes, mark “some- times.”
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54 Month Questionnaire page 5 of 7
(continued)
6. Does your child know the names of numbers? (Mark “yes” if he identi-
fies the three numbers below. Mark “sometimes” if he identifies two
numbers.)
3
1
2
PROBLEM SOLVING TOTAL
PERSONAL-SOCIAL
1. Does your child wash her hands using soap and water and dry off with a towel without help?
2. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)
3. Does your child brush his teeth by putting toothpaste on the tooth- brush and brushing all of his teeth without help? (You may still need to
check and rebrush your child’s teeth.)
4. Does your child serve herself, 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?)
5. 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
6. Does your child dress and undress herself, including buttoning medium-size buttons and zipping front zippers?
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:
NO
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54 Month Questionnaire page 6 of 7
OVERALL (continued)
2. Do you think your child talks like other children her age? If no, explain:
3. Can you understand most of what your child says? If no, explain:
4. Can other people understand most of what your child says? If no, explain:
5. Do you think your child walks, runs, and climbs like other children his age?
If no, explain:
6. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:
7. Do you have any concerns about your child’s vision? If yes, explain:
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54 Month Questionnaire page 7 of 7
8. Has your child had any medical problems in the last several months? If yes, explain:
9. Do you have any concerns about your child’s behavior? If yes, explain:
10. Does anything about your child worry you? If yes, explain:
E101540700
54 Month ASQ-3 Information Summary
51 months 0 days through
56 months 30 days
Child’s name: ________________________________________________________
Date ASQ completed: __________________________________________
Child’s ID #: ______________________________________________________
Date of birth: ______________________________________________
Administering program/provider:
1.SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s 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
0
5
10
15
20
25
30
35
40
45
50
55
60
Area
Cutoff Score
Communication
31.85
Gross Motor
35.18
Fine Motor
17.32
Problem Solving
28.12
Personal-Social
32.33
2.TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
1.
Hears well?
Yes
6.
Family history of hearing impairment?
No
Comments:
2.
Talks like other children his age?
7.
Concerns about vision?
3.
Understand most of what your child says?
8.
Any medical problems?
4.
Others understand most of what your child says?
9.
Concerns about behavior?
5.
Walks, runs, and climbs like other children?
10.
Other concerns?
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 child’s total score is in the If the child’s total score is in the If the child’s total score is in the
area, it is above the cutoff, and the child’s development appears to be on schedule.
area, it is close to the cutoff. Provide learning activities and monitor.
area, it is below the cutoff. Further assessment with a professional may be needed.
4. FOLLOW-UP ACTION TAKEN: Check all that apply.
______
Provide activities and rescreen in _____ months.
Share results with primary health care provider.
Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
Refer to primary health care provider or other community agency (specify
reason): __________________________________________________________.
Refer to early intervention/early childhood special education.
No further action taken at this time
Other (specify): ____________________________________________________
5.OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).
4
6
P101540800
Completing the ASQ 54 Month Questionnaire is an important step in understanding your child's development. After filling out the form, you will need to return it to the designated recipient by the specified date. This process helps gather insights into your child's skills and behaviors.
What is the purpose of the ASQ 54 Month Questionnaire?
The ASQ 54 Month Questionnaire is designed to assess the developmental progress of children aged 51 months to 56 months. It helps parents, guardians, and teachers evaluate key areas such as communication, gross motor skills, fine motor skills, problem-solving abilities, and personal-social skills. By completing this questionnaire, caregivers can identify areas where a child may excel or need additional support, fostering healthy development.
How should I complete the questionnaire?
When filling out the ASQ 54 Month Questionnaire, use black or blue ink and print clearly. Make it a fun activity by engaging your child in the process. Before marking a response, try each activity with your child to see if they can perform it. Ensure your child is well-rested and fed to get the most accurate responses. After completing the questionnaire, return it by the specified deadline.
What should I do if my child is not able to perform certain activities?
If your child cannot perform certain activities listed in the questionnaire, it is important to note this. The questionnaire is a tool for understanding developmental milestones, and not all children develop at the same pace. If your child frequently struggles with activities, consider discussing your observations with a pediatrician or child development specialist for further guidance and support.
Who should fill out the ASQ 54 Month Questionnaire?
The questionnaire should be completed by a person who knows the child well. This could be a parent, guardian, teacher, or childcare provider. It is also helpful to include names of others who assisted in completing the questionnaire, as their insights can provide additional context about the child's development.
Completing the ASQ 54 Month Questionnaire form can be a straightforward process, but there are common mistakes that people often make. These errors can lead to inaccurate assessments of a child's development. Awareness of these pitfalls can help ensure that the questionnaire is filled out correctly.
One frequent mistake is not using the correct writing instrument. The instructions specify using black or blue ink only. Using other colors can make the responses difficult to read, which may lead to misinterpretation of the child's abilities.
Another common error is failing to print legibly. The form requires clear handwriting to ensure that all information is accurately recorded. Illegible writing can result in delays or complications in processing the questionnaire.
People often forget to fill in the date when the ASQ is completed. This date is important for tracking developmental progress over time. Without it, the assessment may lack context, making it challenging to gauge the child's growth.
Some individuals neglect to involve the child in the process. The instructions encourage making the questionnaire a fun game. Skipping this step can lead to incomplete or inaccurate responses, as the child may not be fully engaged during the assessment.
Another mistake involves not trying the activities with the child before marking responses. The questionnaire suggests attempting each activity first. Failing to do so can result in misunderstandings about the child's abilities, leading to inaccurate answers.
In addition, some people may overlook the importance of ensuring that the child is well-rested and fed before completing the questionnaire. A tired or hungry child may not perform at their best, which can skew the results.
People also sometimes forget to include the names of others who assisted in completing the questionnaire. This information can provide valuable context for the evaluators, helping them understand the child's environment and support system.
Lastly, individuals may neglect to review the entire form for completeness before submission. Taking a moment to double-check all sections can help catch any missing information or errors that could affect the assessment's accuracy.
The Ages & Stages Questionnaires® 54 Month Questionnaire form is a valuable tool for assessing a child's development. Alongside this questionnaire, several other forms and documents are often utilized to provide a comprehensive view of a child's growth and needs. Below is a list of these documents, each serving a unique purpose in the evaluation process.
Each of these documents plays a crucial role in understanding and supporting a child's development. By using them in conjunction with the ASQ 54 Month Questionnaire, parents and providers can create a clearer picture of a child's needs and strengths.
When filling out the ASQ 54 Month Questionnaire form, there are several important guidelines to follow. Here are ten recommendations to ensure accurate and effective completion:
The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a valuable tool for assessing child development. However, several misconceptions can arise regarding its purpose and use. Below are six common misconceptions and clarifications for each.
Understanding these misconceptions can help parents and caregivers utilize the ASQ effectively, ensuring that children receive the appropriate support for their developmental needs.
Filling out the ASQ 54 Month Questionnaire form is an important step in assessing a child's development. Here are key takeaways to ensure the process is effective: