The Ages and Stages Questionnaire (ASQ-3) is a screening tool that is used at every Well Child Check from one month to five years. Your provider will ask you to fill out this form to help them evaluate your child’s development.

We recommend filling out this screening tool BEFORE your child’s appointment, because:

• You can save time when you’re at the doctor

• The screening is meant to be done in the child’s normal/usual environment, not in an exam or waiting room

• It’s easier to do on your own time when you and your child are relaxed

INSTRUCTIONS FOR COMPLETING THE SCREENER:

1.Select language in the upper right-hand corner of the screen.

2. Enter your child’s information, and then answer the screening questions.

3. Once you have finished answering the questions you will be asked to enter an email address. This is the way your doctor gets your results. You can only enter one email address. Please enter asq@onecommunityhealth.org or your own email address and forward it to asq@onecommunityhealth.org. This sends the results to your provider so you can review them together at your child’s appointment.

Washington State Parents: Since your child’s provider is based in Oregon you may also fill the ASQ through the Oregon Screening Project Website.

Example:

4. Once you have sent the ASQ screener to your doctor, you can also download your own copy of the results.

ABOUT THE OREGON SCREENING PROJECT

The Oregon Screening Project offers parents an opportunity to complete a free and confidential developmental screening for their children. The Oregon Screening Project was created by the Early Intervention Program at University of Oregon with support from University Center for Excellence in Developmental Disabilities and the Oregon Department of Education.