Ages & Stages Questionnaires (ASQ) are designed to assist our medical staff with identifying and/or monitoring children with possible developmental delays.
These assessment forms can be completed prior to your coinciding wellness appointment and emailed to the office at ncpnurse@gmail.com or brought with you to the appointment. If you are unable to print, a copy will be supplied at your appointment to complete.
***Please be sure to include the child's full name on the form***
1 MO POSTNATAL (pdf)
Download2 MO ASQ (pdf)
Download4 MO ASQ (pdf)
Download6 MO ASQ (pdf)
Download9 MO ASQ (pdf)
Download1 YEAR OLD ASQ (pdf)
Download14 MO ASQ - COMPLETED AT 15 MO (pdf)
Download18 MO ASQ & MCHAT (pdf)
Download2 YEAR OLD ASQ & MCHAT (pdf)
Download2 1/2 YEAR OLD ASQ (pdf)
Download3 YEAR OLD ASQ (pdf)
Download4 YEAR OLD ASQ (pdf)
Download5 YEAR OLD ASQ (pdf)
DownloadPlease complete these screens once a year, during the physical, for children between the ages of 11-17. There is a PARENT version, to be completed by a parent or caregiver and a CHILD version, to be completed by the child. Please complete them independently, as they will be reviewed and compared during the appointment. These screenings help our staff to ensure any cognitive, emotional, and behavioral problems are recognized, so appropriate interventions can be initiated.
These forms only need to be completed if the office staff indicates.
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Please be sure to email us a copy of your child(ren) vaccine card to ncpnurse@gmail.com.