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Blank Asq 54 Month Questionnaire PDF Form

The Ages & Stages Questionnaires® 54 Month Questionnaire is a valuable tool designed to assess the developmental progress of children aged 51 months to 56 months. This questionnaire helps parents and caregivers understand how well their child is meeting key developmental milestones across various areas, including communication, motor skills, and problem-solving. Completing this form can provide essential insights into your child's growth and readiness for the next stages of development, so please take a moment to fill it out by clicking the button below.

Article Guide

The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a valuable tool designed to assess the developmental progress of children aged 51 months to 56 months. This form is structured to gather information about a child's abilities across several key areas, including communication, gross motor skills, fine motor skills, problem-solving, and personal-social development. Caregivers, such as parents, guardians, or teachers, are encouraged to complete the questionnaire by observing the child engaging in various activities. Each section contains specific questions that require the caregiver to evaluate whether the child performs certain tasks regularly, sometimes, or not yet at all. By making the process enjoyable and interactive, caregivers can foster a positive environment for both themselves and the child. Additionally, the form requests essential information about the child and the person completing the questionnaire, ensuring a comprehensive understanding of the child's context. The ASQ 54 Month Questionnaire serves as an essential resource for identifying developmental milestones and potential areas for support, ultimately aiding in the child's growth and learning journey.

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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

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

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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54 Month Questionnaire page 3 of 7

GROSS MOTOR

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

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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	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

54 Month Questionnaire page 4 of 7

FINE MOTOR (continued)

YES

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

YES

SOMETIMES

NOT YET

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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	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

54 Month Questionnaire page 5 of 7

PROBLEM SOLVING	(continued)		YES	SOMETIMES	NOT YET
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

YES

SOMETIMES

NOT YET

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:

YES

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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:	YES	NO

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

YES

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

YES

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

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54 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

10. Does anything about your child worry you? If yes, explain:

YES

E101540700	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

	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	0	5	10	15	20	25	30	35	40	45	50	55	60
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	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 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).

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

P101540800	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

➤ PDF File

Form Specifications

Fact Name	Description
Target Age Range	The ASQ 54 Month Questionnaire is designed for children aged 51 months to 56 months.
Purpose	This questionnaire assesses various developmental milestones in young children.
Completion Method	Parents or guardians should complete the form using black or blue ink and print legibly.
Activities Included	The questionnaire covers communication, gross motor skills, fine motor skills, problem-solving, and personal-social skills.
Response Options	Respondents indicate whether the child performs activities regularly, sometimes, or not yet.
Assistance	It is encouraged to make completing the questionnaire a fun activity for the child.
Submission Deadline	Parents should return the questionnaire by a specified date, which is left blank for completion.
Program Information	The form includes fields for child ID, program ID, and program name for tracking purposes.
Legal Considerations	In some states, the use of developmental screening tools may be governed by specific educational or health regulations.
Publisher	The ASQ-3™ is published by Paul H. Brookes Publishing Co., with copyright protections in place.

Asq 54 Month Questionnaire: Usage Guidelines

Completing the ASQ 54 Month Questionnaire form is an important step in assessing your child's development. Follow the instructions carefully to ensure all necessary information is provided. Once you have filled out the form, return it by the specified date.

Use black or blue ink only. Print legibly throughout the form.
Fill in the date the ASQ was completed at the top of the form.
Provide your child's information:
- Child’s first name and middle initial.
- Child’s last name.
- Child’s gender (Male or Female).
- Child’s date of birth.
Fill in the person completing the questionnaire:
- First name and middle initial.
- Last name.
- Relationship to the child (Parent, Guardian, Teacher, etc.).
Provide your contact information:
- Street address.
- City, State, and ZIP code.
- Country.
- Home and other telephone numbers.
- Email address.
List the names of any people assisting in completing the questionnaire.
Complete the program information section:
- Child ID number.
- Program ID number.
- Program name.
For each activity listed in the questionnaire, mark the appropriate response: YES, SOMETIMES, or NOT YET. Try each activity with your child before marking.
After completing all sections, review the form for accuracy and completeness.
Return the completed questionnaire by the specified date.

Your Questions, Answered

What is the purpose of the ASQ 54 Month Questionnaire?

The ASQ 54 Month Questionnaire is designed to assess a child's development in several key areas: communication, gross motor skills, fine motor skills, problem-solving abilities, and personal-social skills. By answering the questions, parents and caregivers can gain insights into the child's developmental progress and identify any areas where additional support may be beneficial.

Who should complete the ASQ 54 Month Questionnaire?

This questionnaire should be completed by a parent, guardian, teacher, or childcare provider who knows the child well. It’s important that the person filling it out has regular interactions with the child to provide accurate observations. The insights gathered will help in understanding the child's development better.

How should I fill out the ASQ 54 Month Questionnaire?

When filling out the questionnaire, use black or blue ink and print legibly. Each question requires you to indicate whether your child performs certain activities regularly, sometimes, or not yet. It’s a good idea to try each activity with your child before marking your response. Make it a fun experience for both of you!

What if my child is not able to do some of the activities listed?

It’s completely normal for children to develop at different rates. If your child hasn’t yet mastered certain skills or activities, simply mark "not yet" for those items. The questionnaire is designed to capture a snapshot of where your child is in their development, not to judge them. Your observations are valuable in understanding their unique growth journey.

When should I return the completed questionnaire?

Make sure to return the completed questionnaire by the specified deadline indicated on the form. Timely submission ensures that the information can be reviewed and any necessary follow-up can occur. If you have questions about the deadline, reach out to the program or organization that provided the questionnaire.

What should I do with the results of the ASQ 54 Month Questionnaire?

Once completed, the questionnaire can be reviewed by a qualified professional, such as a pediatrician or child development specialist. They can help interpret the results and suggest any next steps if there are areas of concern. It’s a great tool for opening discussions about your child’s development and any support they may need.

Common mistakes

Using the wrong ink color: It's important to use only black or blue ink when filling out the form. Using other colors can make the form difficult to read.
Illegible handwriting: Ensure that all information is printed clearly. Illegible handwriting can lead to misunderstandings or delays in processing.
Incomplete personal information: Make sure to fill in all required fields, including your child's name, date of birth, and your relationship to the child. Missing information can cause issues later.
Not trying activities with the child: It’s crucial to try each activity with your child before marking a response. Skipping this step may lead to inaccurate assessments.
Rushing through the questionnaire: Take your time to ensure that each question is answered thoughtfully. Rushing can result in errors or omissions.
Ignoring the instructions: Pay attention to the instructions provided at the beginning of the form. They contain important information that can affect how you complete the questionnaire.
Failing to return the questionnaire on time: Make sure to submit the completed form by the specified deadline. Late submissions can delay your child's assessment.

Documents used along the form

The Ages & Stages Questionnaires® (ASQ) 54 Month Questionnaire is a valuable tool for assessing child development. However, it is often accompanied by other forms and documents that provide additional context or support. Below is a list of common documents that may be used alongside the ASQ 54 Month Questionnaire.

ASQ-3 Questionnaire: This is the third edition of the Ages & Stages Questionnaire, which assesses developmental milestones from birth to age 5. It covers various domains, including communication, gross motor skills, and problem-solving.
Parent Report Form: This form allows parents to provide detailed information about their child's development and behavior. It often includes open-ended questions that help capture the child's unique experiences.
Developmental History Form: This document gathers information about the child's early development, including milestones reached, health history, and any concerns the parents may have. It provides context for the ASQ results.
Referral Form: If concerns arise from the ASQ results, a referral form may be used to connect families with specialists or services for further evaluation or support.
Consent Form: This form ensures that parents or guardians agree to the assessment process and understand how the information will be used. It is essential for maintaining privacy and compliance with regulations.
Observation Checklist: This checklist helps caregivers document specific behaviors or skills observed in the child during everyday activities. It can complement the ASQ findings by providing real-life examples.
Service Plan: For children who may require additional support, a service plan outlines the goals and strategies to address developmental needs. It often involves collaboration between parents and professionals.
Feedback Form: After completing the ASQ, parents may receive a feedback form that summarizes the results and provides recommendations for activities to support their child's development.
Follow-Up Questionnaire: This document may be used to gather additional information after a specific period, allowing for tracking of developmental progress and any changes in concerns.

These forms and documents work together to create a comprehensive picture of a child's development, ensuring that parents and professionals can make informed decisions about support and interventions. By utilizing this array of resources, families can better understand their child's unique developmental journey.

Similar forms

Denver Developmental Screening Test (DDST): Like the ASQ 54 Month Questionnaire, the DDST assesses a child's development in areas such as gross motor, fine motor, language, and personal-social skills. Both tools provide a structured way for caregivers to evaluate developmental milestones.
Child Development Inventory (CDI): The CDI is a parent-completed questionnaire that evaluates a child's development across various domains. Similar to the ASQ, it focuses on developmental milestones and can help identify areas where a child may need additional support.
Brigance Developmental Inventory: This tool assesses children from birth to age 7 and covers multiple developmental areas. Like the ASQ, it includes observations and parent input to gauge a child's progress and readiness for school.
Bayley Scales of Infant and Toddler Development: The Bayley scales evaluate developmental functioning in infants and toddlers. It shares similarities with the ASQ by providing a comprehensive assessment of cognitive, language, motor, social-emotional, and adaptive behavior skills.
Developmental Assessment of Young Children (DAYC): The DAYC assesses development in children from birth to age 5. Similar to the ASQ, it includes input from caregivers and focuses on key developmental areas, making it a valuable screening tool.
Mullen Scales of Early Learning: This assessment tool measures early learning skills in children from birth to 68 months. Like the ASQ, it evaluates multiple domains, providing insight into a child's developmental progress.
Ages & Stages Questionnaires: Social-Emotional (ASQ:SE): The ASQ:SE specifically focuses on social-emotional development, similar to the ASQ 54 Month Questionnaire. It helps identify children who may be at risk for social-emotional difficulties.
Pediatric Symptom Checklist (PSC): The PSC is a screening tool for behavioral and emotional problems in children. While it focuses on different aspects than the ASQ, both aim to identify areas where children may need further evaluation or support.
Vineland Adaptive Behavior Scales: This tool assesses personal and social skills in children and adolescents. Like the ASQ, it emphasizes everyday skills and behaviors, providing a comprehensive view of a child's adaptive functioning.
Early Screening Inventory (ESI): The ESI evaluates a child's readiness for school by assessing developmental skills. Similar to the ASQ, it includes various domains and is designed to identify children who may benefit from early intervention.

Dos and Don'ts

When filling out the ASQ 54 Month Questionnaire form, it is important to follow certain guidelines to ensure clarity and accuracy. Below is a list of things you should and should not do:

Do use black or blue ink only.
Do print legibly to ensure all information is clear.
Do make completing the questionnaire a fun activity for you and your child.
Do ensure your child is well-rested and fed before starting.
Don't rush through the questionnaire; take your time to think about each response.
Don't provide assistance or hints to your child when asking questions.

Misconceptions

Here are some common misconceptions about the ASQ 54 Month Questionnaire form:

It is only for parents to fill out. Many people believe that only parents can complete this questionnaire. In reality, anyone who is involved in the child's care, such as teachers or childcare providers, can fill it out. Their insights can provide a well-rounded view of the child's development.
It measures only academic skills. Some think the questionnaire focuses solely on academic abilities. However, it covers a wide range of developmental areas, including communication, gross motor skills, fine motor skills, problem-solving, and personal-social skills. This comprehensive approach helps capture a child's overall development.
Responses must be perfect. There is a misconception that parents should have all the answers correct. The purpose of the questionnaire is to gauge the child's development, not to achieve a perfect score. It's okay if a child is not performing all activities yet; the goal is to understand where they are in their developmental journey.
It is a one-time assessment. Some believe that the ASQ is a one-time evaluation of a child's abilities. In truth, it is meant to be used periodically to track progress over time. Regular assessments can help identify areas where a child may need additional support.

Key takeaways

When filling out the ASQ 54 Month Questionnaire form, keep the following key takeaways in mind:

Use the correct ink: Always use black or blue ink to ensure clarity and legibility.
Print clearly: Fill out the form legibly, as this helps avoid any confusion during the review process.
Engage your child: Make the completion of the questionnaire a fun activity. This can help your child feel more comfortable and cooperative.
Check your child’s readiness: Ensure your child is well-rested and fed before starting, as this can affect their performance on the activities.
Follow the instructions: For each activity, try it with your child before marking a response to get an accurate assessment of their abilities.
Return the form on time: Make sure to submit the completed questionnaire by the specified deadline to ensure timely processing.