ASQ-3 – 04 Month Questionnaire - Pediatric People

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ASQ-3 – 04 Month QuestionnaireMichael2025-08-07T15:40:32-05:00

4 MONTH ASSESSMENT

"*" indicates required fields

PATIENT NAME*

First Last

DATE OF BIRTH*

Month

Day

Year

FORM COMPLETED BY*

First Last

1. Does your baby chuckle softly?*

YES

SOMETIMES

NOT YET

2. After you have been out of sight, does your baby smile or get excited when he sees you?*

YES

SOMETIMES

NOT YET

3. Does your baby stop crying when she hears a voice other than yours?*

YES

SOMETIMES

NOT YET

4. Does your baby make high-pitched squeals?*

YES

SOMETIMES

NOT YET

5. Does your baby laugh?*

YES

SOMETIMES

NOT YET

6. Does your baby make sounds when looking at toys or people?*

YES

SOMETIMES

NOT YET

1. While your baby is on his back, does he move his head from side to side?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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.)*

YES

SOMETIMES

NOT YET

5. When you hold him in a sitting position, does your baby hold his head steady?*

YES

SOMETIMES

NOT YET

6. While your baby is on her back, does your baby bring her hands together over her chest, touching her fingers?*

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)?*

YES

SOMETIMES

NOT YET

2. When you put a toy in her hand, does your baby wave it about, at least briefly?*

YES

SOMETIMES

NOT YET

3. Does your baby grab or scratch at his clothes?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

4. When you put a toy in her hand, does your baby look at it?*

YES

SOMETIMES

NOT YET

5. When you put a toy in his hand, does your baby put the toy in his mouth?*

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?*

YES

SOMETIMES

NOT YET

1. Does your baby watch his hands?*

YES

SOMETIMES

NOT YET

2. When your baby has her hands together, does she play with her fingers?*

YES

SOMETIMES

NOT YET

3. When your baby sees the breast or bottle, does he seem to know he is about to be fed?*

YES

SOMETIMES

NOT YET

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?*

YES

SOMETIMES

NOT YET

5. Before you smile or talk to your baby, does he smile when he sees you nearby?*

YES

SOMETIMES

NOT YET

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

YES

SOMETIMES

NOT YET

1. Does your baby use both hands and both legs equally well?*

YES

NO

Please explain:*

2. When you help your baby stand, are his feet flat on the surface most of the time?*

YES

NO

Please explain:*

3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?*

YES

NO

Please explain:*

4. Does either parent have a family history of childhood deafness or hearing impairment?*

YES

NO

Please explain:*

5. Do you have concerns about your baby’s vision*

YES

NO

Please explain:*

6. Has your baby had any medical problems in the last several months?*

YES

NO

Please explain:*

7. Do you have any concerns about your baby’s behavior?*

YES

NO

Please explain:*

8. Does anything about your baby worry you?*

YES

NO

Please explain:*