ASQ

Click on appropriate age questionnaire, fill out and print (please do not staple pages). Please bring to the next well visit. You can also save the form to a PDF and email it to email@pediatric-care.org

1 to 4 Months

Intervention Activities 1-4 Mo

02 month AS Questionnaire (1 months 0 days to 2 months 30 days)
04 month AS Questionnaire (3 months 0 days to 4 months 30 days)

4 to 8 Months

Intervention Activities 4-8 Mo

06 month AS Questionnaire (5 months 0 days to 6 month 30 days)

8 to 12 Months

Intervention Activities 8-12 Mo

08 month AS Questionnaire (7 months 0 days to 8 months 30 days)
09 month AS Questionnaire (9 months 0 days to  9 months 30 days)
10 month AS Questionnaire (10 months 0 days to 10 months 30 days)

12 to 16 Months

Intervention Activities 12-16 Mo

12 month AS Questionnaire (11 months 0 days to 13 months 30 days)
14 month AS Questionnaire (14 months 0 days to 14 months 30 days)
16 month AS Questionnaire (15 months 0 days to 16 months 30 days)

16 to 20 Months

Intervention Activities 16-20 Mo

18 month AS Questionnaire (17 months 0 days to 18 months 30 days)
20 month AS Questionnaire (19 months 0 days to 20 months 30 days)

20 to 24 Months

Intervention Activities 20-24 Mo

22 month AS Questionnaire (21 months 0 days to 22 months 30 days)
24 month AS Questionnaire (23 months 0 days to 25 months 15 days)

24 to 30 Months

Intervention Activities 24-30 Mo

27 month AS Questionnaire (25 months 16 days to 28 months 15 days)
30 month  AS Questionnaire (28 months 16 days to 31 months 15 days)

30 to 36 Months

Intervention Activities 30-36 Mo

33 month AS Questionnaire (31 months 16 days to 34 months 15 days)
36 month AS Questionnaire (34 months 16 days to 38 months 30 days)

36 to 48 Months

Intervention Activities 36-48 Mo

42 month AS Questionnaire (39 Months 0 days to 44 months 30 days)
48 month AS Questionnaire (45 Months 0 days to 50 months 30 days)

48 to 60 Months

Intervention Activities 48-60 Mo

54 month AS Questionnaire (51 months 0 days to 56 months 30 days)
60 month AS Questionnaire (57 months 0 days to 66 months 30 days)

60 to 66 Months

Intervention Activities 60-66 Mo

60 month AS Questionnaire (57 months 0 days to 66 months 30 days)