Ages and Stages Questionnaire - 2 month English

Ages & Stages
Questionnaires®

2 Month Questionnaire

1 month 0 days through 2 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:

P101020100

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

Child care
provider

2 Month Questionnaire

1 month 0 days
through 2 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 sometimes make throaty or gurgling sounds?
2. Does your baby make cooing sounds such as “ooo,” “gah,” and “aah”?
3. When you speak to your baby, does she make sounds back to you?
4. Does your baby smile when you talk to him?
5. Does your baby chuckle softly?
6. After you have been out of sight, does your baby smile or get excited
when she sees you?

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. While your baby is on his back, does he wave his arms and legs, wiggle,
and squirm?
2. When your baby is on her tummy, does she turn her head to the side?
3. When your baby is on his tummy, does he hold his head up longer than
a few seconds?
4. When your baby is on her back, does she kick her legs?
5. While your baby is on his back, does he move his head from side to side?
6. 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?

GROSS MOTOR TOTAL

page 2 of 5

E101020200

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

2 Month Questionnaire
FINE MOTOR

YES

SOMETIMES

page 3 of 5

NOT YET

1. Is your baby’s hand usually tightly closed when he is awake? (If your
baby used to do this but no longer does, mark “yes.”)

2. Does your baby grasp your finger if you touch
the palm of her hand?

3. When you put a toy in his hand, does your baby hold it
in his hand briefly?

4. Does your baby touch her face with her hands?
*

5. Does your baby hold his hands open or partly open when
he is awake (rather than in fists, as they were when he was
a newborn)?
6. Does your baby grab or scratch at her clothes?

FINE MOTOR TOTAL
*If Fine Motor item 5 is marked “yes,”
mark Fine Motor item 1 as “yes.”

PROBLEM SOLVING

YES

SOMETIMES

NOT YET

1. Does your baby look at objects that are 8–10 inches away?
2. When you move around, does your baby follow you with his eyes?
3. 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 her
eyes, sometimes turning her head?
4. 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 his eyes?
5. When you hold your baby in a sitting position, does she look at a toy
(about the size of a cup or rattle) that you place on the table or floor in
front of her?

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

PROBLEM SOLVING TOTAL

E101020300

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

2 Month Questionnaire
PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. Does your baby sometimes try to suck, even when she’s not feeding?
2. Does your baby cry when he is hungry, wet, tired, or wants to be held?
3. Does your baby smile at you?
4. When you smile at your baby, does she smile back?

5. Does your baby watch his hands?

6. When your baby sees the breast or bottle, does she seem to know she
is about to be fed?

PERSONAL-SOCIAL TOTAL

OVERALL
Parents and providers may use the space below for additional comments.
1. Did your baby pass the newborn hearing screening test? If no, explain:

YES

NO

2. Does your baby move both hands and both legs equally well? If no,
explain:

YES

NO

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

YES

NO

E101020400

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

page 4 of 5

2 Month Questionnaire
OVERALL

(continued)

4. Has your baby had any medical problems? If yes, explain:

YES

NO

5. Do you have concerns about your baby’s behavior (for example, eating,
sleeping)? If yes, explain:

YES

NO

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

YES

NO

E101020500

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

page 5 of 5

2 Month ASQ-3 Information Summary

1 months 0 days through
2 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

22.77

Gross Motor

41.84

Fine Motor

30.16

Problem Solving

24.62

Personal-Social

33.71

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.

Passed newborn hearing screening test?
Comments:

Yes

NO

4.

Any medical problems?
Comments:

YES

No

2.

Moves both hands and both legs equally well?
Comments:

Yes

NO

5.

Concerns about behavior?
Comments:

YES

No

3.

Family history of hearing impairment?
Comments:

YES

No

6.

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): ____________________________________________________

P101020600

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

2

3

4

5

6