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 email@example.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)Download
2 MO ASQ (pdf)Download
4 MO ASQ (pdf)Download
6 MO ASQ (pdf)Download
9 MO ASQ (pdf)Download
1 YEAR OLD ASQ (pdf)Download
14 MO ASQ - COMPLETED AT 15 MO (pdf)Download
18 MO ASQ & MCHAT (pdf)Download
2 YEAR OLD ASQ & MCHAT (pdf)Download
2 1/2 YEAR OLD ASQ (pdf)Download
3 YEAR OLD ASQ (pdf)Download
4 YEAR OLD ASQ (pdf)Download
5 YEAR OLD ASQ (pdf)Download
Please 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.