Healthcare ASQ-3 Set

Healthcare ASQ-3 Set

Patient Information

Date of Birth:

Insurance / Responsible Party

Screening Information and Consent

ASQ-3 Interval (age in months):

Screening Date:

Assessor / Clinician:

I consent to the administration of the ASQ-3 developmental screening for the child named above. I understand the screening is a brief standardized parent-completed tool used to identify developmental concerns. I authorize the results to be recorded in the patient's medical record and shared with caregivers and appropriate service providers as necessary for care coordination. I understand I may withdraw consent at any time by notifying the clinic in writing.

Questionnaire — Communication

Please answer each item based on your child's typical behavior during the past month.

1. Says two or more words together Yes Sometimes Not yet

2. Responds to name when called Yes Sometimes Not yet

3. Uses gestures (pointing, waving) to get attention Yes Sometimes Not yet

4. Follows simple directions without gestures Yes Sometimes Not yet

5. Looks where you point to indicate interest Yes Sometimes Not yet

6. Uses words or sounds to express needs Yes Sometimes Not yet

Gross Motor

1. Walks up and down steps with support Yes Sometimes Not yet

2. Runs easily Yes Sometimes Not yet

3. Kicks a large ball forward Yes Sometimes Not yet

4. Climbs onto furniture unassisted Yes Sometimes Not yet

5. Balances briefly on one foot Yes Sometimes Not yet

6. Jumps with both feet off the ground Yes Sometimes Not yet

Fine Motor

1. Builds a tower of blocks Yes Sometimes Not yet

2. Uses a crayon to make marks Yes Sometimes Not yet

3. Picks up small objects using thumb and index finger Yes Sometimes Not yet

4. Turns pages in a book one at a time Yes Sometimes Not yet

5. Strings large beads or puts objects through holes Yes Sometimes Not yet

6. Imitates drawing a line or simple shapes Yes Sometimes Not yet

Problem Solving

1. Finds a hidden object under a cup Yes Sometimes Not yet

2. Matches simple shapes or objects Yes Sometimes Not yet

3. Completes a simple three-piece puzzle Yes Sometimes Not yet

4. Uses objects appropriately (e.g., pushes car to make it go) Yes Sometimes Not yet

5. Solves simple problems without adult help Yes Sometimes Not yet

6. Begins to use objects to achieve goals Yes Sometimes Not yet

Personal-Social

1. Plays with other children or engages in parallel play Yes Sometimes Not yet

2. Shows affection to familiar people Yes Sometimes Not yet

3. Feeds self with spoon or fork Yes Sometimes Not yet

4. Removes some clothing items independently Yes Sometimes Not yet

5. Shows concern for others (e.g., comforts when upset) Yes Sometimes Not yet

6. Follows simple daily routines Yes Sometimes Not yet

Scoring, Recommendations, and Follow-Up

Scoring: Record the total score for each domain above. Scores falling below established cutoff scores indicate the need for further assessment or referral. The clinician is responsible for interpreting scores, documenting parental concerns, and arranging follow-up or referral when indicated.

No further action at this time; continue routine monitoring
Monitor and repeat ASQ in specified interval
Schedule provider follow-up for developmental concerns
Refer to early intervention / specialized services
Recommend comprehensive developmental evaluation

Privacy, Release, and Authorization

By checking the box below and signing, I acknowledge that I have been informed of the clinic's privacy practices and consent to the disclosure of screening results to other healthcare or early intervention providers when necessary for care coordination or referral. I authorize the release of ASQ-3 results and related clinical notes for the purpose of diagnostic assessment or service provision. This authorization is voluntary and may be revoked in writing; however, revocation will not affect disclosures already made in reliance on this authorization.

I acknowledge receipt of the clinic privacy notice and authorize release/sharing of ASQ-3 results as described above.

Authorization Expiration Date:

Parent / Caregiver provided additional information: Yes

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