Ages & Stages

Questionnaires®

42 Month Questionnaire
39 months 0 days through 44 months 30 days

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

Middle
First name: initial: Last name:
Relationship to child:
Parent Guardian Teacher Child care
provider
Street address: Grandparent Foster
or other parent Other:
relative

State/ ZIP/
City: Province: Postal code:

Home Other
telephone telephone
Country: number: number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information

Child ID #:

Program ID #:

Program name:

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
P101420100 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire 39 months 0 days
through 44 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: Notes:

✓ 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 _______________.
❑ ____________________________________________

COMMUNICATION YES SOMETIMES NOT YET

1. Without giving your child help by pointing or using gestures, ask him to
“put the book on the table” and “put the shoe under the chair.” Does
your child carry out both of these directions correctly?

2. When looking at a picture book, does your child tell you what is hap-
pening or what action is taking place in the picture (for example, “bark-
ing,” “running,” “eating,” or “crying”)? You may ask, “What is the dog
(or boy) doing?”

3. Show your child how a zipper on a coat moves up and down, and say,
“See, this goes up and down.” Put the zipper to the middle, and ask
your child to move the zipper down. Return the zipper to the middle,
and ask your child to move the zipper up. Do this several times, placing
the zipper in the middle before asking your child to move it up or
down. Does your child consistently move the zipper up when you say
“up” and down when you say “down”?

4. When you ask, “What is your name?” does your child say both her first
and last names?

5. Without your 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.”

6. Does your child use all of the words in a sentence (for example, “a,”
“the,” “am,” “is,” and “are”) to make complete sentences, such as “I
am going to the park,” or “Is there a toy to play with?” or “Are you
coming, too?”

COMMUNICATION TOTAL

page 2 of 7
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E101420200 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire page 3 of 7

GROSS MOTOR YES SOMETIMES NOT YET

1. Does your child walk up stairs, using only one foot on each
stair? (The left foot is on one step, and the right foot is on
the next.) He may hold onto the railing or wall. (You can
look for this at a store, on a playground, or at home.)

2. Does your child stand on one foot for about 1 second

without holding onto anything?

3. While standing, does your child throw a ball overhand by

raising his arm to shoulder height and throwing the ball
forward? (Dropping the ball or throwing the ball under-
hand should be scored as “not yet.”)

4. Does your child jump forward at least 6 inches with both

feet leaving the ground at the same time?

5. 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.)

6. Does your child climb the rungs of a ladder of a playground slide and
slide down without help?

GROSS MOTOR TOTAL

FINE MOTOR YES SOMETIMES NOT YET

Count as “yes”

1. After your child watches you draw a single circle with a

pencil, crayon, or pen, ask him to make a circle like
yours. Do not let him trace your circle. Does your child Count as “not yet”
copy you by drawing a circle?

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101420300 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire page 4 of 7

FINE MOTOR (continued) YES SOMETIMES NOT YET

Count as “yes”
2. After your child watches you draw a line from one
side of the paper to the other side, ask her to make
a line like yours. Do not let your child trace your line.
Does your child copy you by drawing a single line in Count as “not yet”
a horizontal direction?

3. Does your child try to cut paper with child-safe scissors?

He does not need to cut the paper but must get the
blades to open and close while holding the paper with
the other hand. (You may show your child how to use
scissors. Carefully watch your child’s use of scissors for
safety reasons.)

4. When drawing, does your child hold a pencil, crayon, or

pen between her fingers and thumb like an adult does?

5. Does your child put together a five- to seven-piece interlocking puzzle?

(If one is not available, take a full-page picture from a magazine or cata-
log and cut it into six pieces. Does your child put it back together cor-
rectly?)

6. Using the shape at right to look at, does your child copy it
onto a large piece of paper using a pencil, crayon, or pen,
without tracing? (Your child’s drawing should look like the
design of the shape, except it may be different in size.) FINE MOTOR TOTAL

PROBLEM SOLVING YES SOMETIMES NOT YET

1. When you point to the figure and ask your child, “What is
this?” does your child say a word that means a person or
something similar? (Mark “yes” for responses like “snowman,”
“boy,” “man,” “girl,” “Daddy,” “spaceman,” and “monkey.”)
Please write your child’s response here:

2. When you say, “Say ‘seven three,’” does your child repeat just the two
numbers in the same order? Do not repeat the numbers. If necessary,
try another pair of numbers and say, “Say ‘eight two.’” (Your child must
repeat just one series of two numbers for you to answer “yes” to this
question.)

3. Show your child how to make a bridge with blocks, boxes,

or cans, like the example. Does your child copy you by
making one like it?

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101420400 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire page 5 of 7

PROBLEM SOLVING (continued) YES SOMETIMES NOT YET

4. When you say, “Say ‘five eight three,’” does your child repeat just the
three numbers in the same order? Do not repeat the numbers. If neces-
sary, try another series of numbers and say, “Say ‘six nine two.’” (Your
child must repeat just one series of three numbers for you to answer
“yes” to this question.)

5. When asked, “Which circle is the smallest?” does your child point to
the smallest circle? (Ask this question without providing help by point-
ing, gesturing, or looking at the smallest circle.)

6. 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 or sister, or an
imaginary animal or figure. PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL YES SOMETIMES NOT YET

1. When he is looking in a mirror and you ask, “Who is in the mirror?”

does your child say either “me” or his own name?

2. Does your child put on a coat, jacket, or shirt by herself?

3. Using these exact words, ask your child, “Are you a girl or a boy?”
Does your child answer correctly?

4. Does your child take turns by waiting while another child or adult takes
a turn?

5. Does your child serve himself, 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?

6. Does your child wash his hands using soap and water and dry off with a
towel without help?

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: YES NO

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101420500 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire page 6 of 7

OVERALL (continued)

2. Do you think your child talks like other children her age? If no, explain: YES NO

3. Can you understand most of what your child says? If no, explain: YES NO

4. Can other people understand most of what your child says? If no, explain: YES NO

5. Do you think your child walks, runs, and climbs like other children his age? YES NO
If no, explain:

6. Does either parent have a family history of childhood deafness or hearing YES NO
impairment? If yes, explain:

7. Do you have any concerns about your child’s vision? If yes, explain: YES NO

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101420600 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month Questionnaire page 7 of 7

OVERALL (continued)

8. Has your child had any medical problems in the last several months? If yes, explain: YES NO

9. Do you have any concerns about your child’s behavior? If yes, explain: YES NO

10. Does anything about your child worry you? If yes, explain: YES NO

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
E101420700 © 2009 Paul H. Brookes Publishing Co. All rights reserved.
 42 Month ASQ-3 Information Summary 39 months 0 days through
44 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
Area Cutoff Score 0 5 10 15 20 25 30 35 40 45 50 55 60
Communication 27.06
Gross Motor 36.27
Fine Motor 19.82
Problem Solving 28.11
Personal-Social 31.12

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.

1. Hears well? Yes NO 6. Family history of hearing impairment? YES No

Comments: Comments:

2. Talks like other children his age? Yes NO 7. Concerns about vision? YES No
Comments: Comments:

3. Understand most of what your child says? Yes NO 8. Any medical problems? YES No
Comments: Comments:

4. Others understand most of what your child says? Yes NO 9. Concerns about behavior? YES No
Comments: Comments:

5. Walks, runs, and climbs like other children? Yes NO 10. Other concerns? YES No
Comments: Comments:

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 area, it is above the cutoff, and the child’s development appears to be on schedule.
If the child’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor.
If the child’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply. 5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
______ Provide activities and rescreen in _____ months.
X = response missing).
______ Share results with primary health care provider.
1 2 3 4 5 6
______ Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
Communication
______ Refer to primary health care provider or other community agency (specify
Gross Motor
reason): __________________________________________________________.
Fine Motor
______ Refer to early intervention/early childhood special education.
Problem Solving
______ No further action taken at this time
Personal-Social
______ Other (specify): ____________________________________________________

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
P101420800 © 2009 Paul H. Brookes Publishing Co. All rights reserved.