Ages and Stages Questionnaire - 4 month English

Ages & Stages
Questionnaires®

4 Month Questionnaire

3 months 0 days through 4 months 30 days

Please provide the following information. Use black or blue ink only and print
legibly when completing this form.

Date ASQ completed:

Baby’s information
Middle
initial:

Baby’s first name:

Baby’s last name:
If baby was born 3
or more weeks
prematurely, # of
weeks premature:

Baby’s date of birth:

Baby’s gender:
Male

Female

Person filling out questionnaire
Middle
initial:

First name:

Last name:
Relationship to baby:

Street address:

Parent

Guardian

Teacher

Grandparent
or other
relative

Foster
parent

Other:

City:

State/
Province:

ZIP/
Postal code:

Country:

Home
telephone
number:

Other
telephone
number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information
Baby ID #:

Age at administration in months and days:

Program ID #:

If premature, adjusted age in months and days:

Program name:

P101040100

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

Child care
provider

4 Month Questionnaire

3 months 0 days
through 4 months 30 days

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities
described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:
✓ Try each activity with your baby before marking a response.
❑
✓ Make completing this questionnaire a game that is fun for
❑
you and your baby.

Notes:
____________________________________________
____________________________________________

✓ Make sure your baby is rested and fed.
❑

____________________________________________

✓ Please return this questionnaire by _______________.
❑

____________________________________________

COMMUNICATION

YES

SOMETIMES

NOT YET

1. Does your baby chuckle softly?
2. After you have been out of sight, does your baby smile or get excited
when he sees you?
3. Does your baby stop crying when she hears a voice other than yours?
4. Does your baby make high-pitched squeals?
5. Does your baby laugh?
6. Does your baby make sounds when looking at toys or people?

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. While your baby is on his back, does he move his head from side to
side?
2. After holding her head up while on her tummy, does your baby lay her
head back down on the floor, rather than let it drop or fall forward?
3. When your baby is on his tummy, does he hold his
head up so that his chin is about 3 inches from the
floor for at least 15 seconds?
4. When your baby is on her tummy, does she hold her
head straight up, looking around? (She can rest on her
arms while doing this.)

page 2 of 5

E101040200

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

4 Month Questionnaire
GROSS MOTOR

(continued)

YES

SOMETIMES

NOT YET

5. When you hold him in a sitting position, does your baby hold his head
steady?
6. While your baby is on her back, does your
baby bring her hands together over her chest,
touching her fingers?

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. Does your baby hold his hands open or partly open (rather
than in fists, as they were when he was a newborn)?

2. When you put a toy in her hand, does your baby wave it about, at least
briefly?
3. Does your baby grab or scratch at his clothes?
4. When you put a toy in her hand, does your baby hold onto it for about
1 minute while looking at it, waving it about, or trying to chew it?
5. Does your baby grab or scratch his fingers on a surface in front of him,
either while being held in a sitting position or when he is on his tummy?
6. When you hold your baby in a sitting position, does she reach for a toy
on a table close by, even though her hand may not touch it?

FINE MOTOR TOTAL

PROBLEM SOLVING

YES

1. When you move a toy slowly from side to side in front of your baby’s
face (about 10 inches away), does your baby follow the toy with his
eyes, sometimes turning his head?
2. When you move a small toy up and down slowly in front of your baby’s
face (about 10 inches away), does your baby follow the toy with her
eyes?
3. When you hold your baby in a sitting position, does he look at a toy
(about the size of a cup or rattle) that you place on the table or floor in
front of him?
4. When you put a toy in her hand, does your baby look at it?
5. When you put a toy in his hand, does your baby put the toy in his
mouth?

E101040300

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

SOMETIMES

NOT YET

page 3 of 5

4 Month Questionnaire
PROBLEM SOLVING

(continued)

YES

SOMETIMES

NOT YET

6. When you dangle a toy above your baby while she
is lying on her back, does your baby wave her arms
toward the toy?

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. Does your baby watch his hands?

2. When your baby has her hands together, does she play with her
fingers?
3. When your baby sees the breast or bottle, does he seem to know he is
about to be fed?
4. Does your baby help hold the bottle with both hands at once, or when
nursing, does she hold the breast with her free hand?
5. Before you smile or talk to your baby, does he smile when he sees you
nearby?

6. When in front of a large mirror, does your baby
smile or coo at herself?

PERSONAL-SOCIAL TOTAL

OVERALL
Parents and providers may use the space below for additional comments.
1. Does your baby use both hands and both legs equally well? If no,
explain:

YES

NO

2. When you help your baby stand, are his feet flat on the surface most
of the time? If no, explain:

YES

NO

E101040400

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

page 4 of 5

4 Month Questionnaire
OVERALL

(continued)

3. Do you have concerns that your baby is too quiet or does not make sounds like
other babies? If yes, explain:

YES

NO

4. Does either parent have a family history of childhood deafness or hearing
impairment? If yes, explain:

YES

NO

5. Do you have concerns about your baby’s vision? If yes, explain:

YES

NO

6. Has your baby had any medical problems in the last several months?
If yes, explain:

YES

NO

7. Do you have any concerns about your baby’s behavior? If yes, explain:

YES

NO

8.

YES

NO

Does anything about your baby worry you? If yes, explain:

E101040500

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

page 5 of 5

4 Month ASQ-3 Information Summary

3 months 0 days through
4 months 30 days

Baby’s name: ______________________________________________________ Date ASQ completed: __________________________________________
Baby’s ID #: ______________________________________________________ Date of birth: ______________________________________________
Was age adjusted for prematurity
when selecting questionnaire?

Administering program/provider:

Yes

No

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.

2.

3.

Area

Cutoff

Communication

34.60

Gross Motor

38.41

Fine Motor

29.62

Problem Solving

34.98

Personal-Social

33.16

Total
Score

0

5

10

15

20

25

30

35

40

45

50

55

60

TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
1. Uses both hands and both legs equally well?
Comments:

Yes

NO

5. Concerns about vision?
Comments:

YES

No

2. Feet are flat on the surface most of the time?
Comments:

Yes

NO

6. Any medical problems?
Comments:

YES

No

3. Concerns about not making sounds?
Comments:

YES

No

7. Concerns about behavior?
Comments:

YES

No

4. Family history of hearing impairment?
Comments:

YES

No

8. Other concerns?
Comments:

YES

No

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 baby’s total score is in the
If the baby’s total score is in the
If the baby’s total score is in the

area, it is above the cutoff, and the baby’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.

5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
X = response missing).

______ 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

1
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social

______ Other (specify): ____________________________________________________

P101040600

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

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