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Here for a Well Visit or Physical?

Is your child 5 years of age or younger?

If you answered yes to both of these questions, there is a screening tool we use called the Ages & Stages Questionnaire (ASQ). We use this tool to screen your child's motor and language development based on their age. We also screen for autism and autism-related conditions around 18 to 24 months of age using the M-CHAT form.

The ASQ can take some time to complete, especially for older toddlers. For some questions you may need to have your child perform simple tasks to provide the most accurate answer - and we all understand how sometimes our children do not feel like performing those tasks the moment we ask them.

By completing the appropriate form within a few days prior to the appointment, it can be done in familiar surroundings and at a place and time where your child may feel more comfortable participating.

How do I know which form(s) to choose?

Click here to open the ASQ Age Calculator to determine which form listed below is most appropriate for your child.

Please click on the link for the most appropriate ASQ form based on your child's age in months. Print the form and complete with your child up to a few days prior to the appointment.

If there is also a link for the MCHAT form next to the needed ASQ , please click on that link to print and complete that form also.

Please bring the completed form(s) with you and your child to the appointment.

Forms

ASQ 2 month Questionnaire
Use for child aged 1 month + 0 days through 2 months + 30 days

ASQ 4 month Questionnaire
Use for child aged 3 months + 0 days through 4 months + 30 days

ASQ 6 month Questionnaire
Use for child aged 5 months + 0 days through 6 months + 30 days

ASQ 8 month Questionnaire
Use for child aged 7 months + 0 days through 8 months + 30 days

ASQ 9 month Questionnaire
Use for child aged 9 months + 0 days through 9 months + 30 days

ASQ 10 month Questionnaire
Use for child aged 9 months + 0 days through 10 months + 30 days

ASQ 12 month Questionnaire
Use for child aged 11 months + 0 days through 12 months + 30 days

ASQ 14 month Questionnaire
Use for child aged 13 months + 0 days through 14 months + 30 days

ASQ 16 month Questionnaire
Use for child aged 15 months + 0 days through 16 months + 30 days

ASQ 18 month Questionnaire and M-CHAT (autism screening)
Use for child aged 17 months + 0 days through 18 months + 30 days

ASQ 20 month Questionnaire and M-CHAT (autism screening)
Use for child aged 19 months + 0 days through 20 months + 30 days

ASQ 22 month Questionnaire and M-CHAT (autism screening)
Use for child aged 21 months + 0 days through 22 months + 30 days

ASQ 24 month Questionnaire and M-CHAT (autism screening)
Use for child aged 23 months + 0 days through 25 months + 15 days

ASQ 27 month Questionnaire and M-CHAT (autism screening)
Use for child aged 25 months + 16 days through 28 months + 15 days

ASQ 30 month Questionnaire
Use for child aged 28 months + 16 days through 31 months + 15 days

ASQ 33 month Questionnaire
Use for child aged 31 months + 16 days through 34 months + 15 days

ASQ 36 month Questionnaire
Use for child aged 34 months + 16 days through 38 months + 30 days

ASQ 42 month Questionnaire
Use for child aged 39 months + 0 days through 44 months + 30 days

ASQ 48 month Questionnaire
Use for child aged ;45 months + 0 days through 50 months + 30 days

ASQ 54 month Questionnaire
Use for child aged 51 months + 0 days through 56 months + 30 days

ASQ 60 month Questionnaire
Use for child aged 57 months + 0 days through 66 months + 0 days

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