48 Month 2

Questionnaire
42 months 0 days through 53 months 30 days S E CO N D E D I T I O N

Date ASQ:SE-2 completed: _____________________________________________________

Child’s information

Child’s first name: Child’s middle initial: Child’s last name:

Child’s date of birth:

Child’s gender: ◯ Male ◯ Female

Person filling out questionnaire

First name: Middle initial: Last name:

Street address:

State/
City: province: ZIP/postal code:
Home Other
telephone telephone
Country: number: number:

E-mail address:
Relationship to child: ◯ Parent ◯ Guardian ◯ Teacher ◯ Other:
◯ other relative ◯ Foster
Grandparent/
parent
◯ Child care
provider

People assisting in questionnaire completion:

Program information (For program use only.)

Age at administration
Child’s ID #: in months and days:

Program ID #:

Program name:

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.
P201480000 © 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.
 48 Month Questionnaire 42 months 0 days through 53 months 30 days 2
Questions about behaviors children may have are listed on the following pages. Please read each question carefully and check the
box that best describes your child’s behavior. Also, check the circle if the behavior is a concern.

Important Points to Remember:

❏ Answer questions based on what you know about your ❏ Please return this questionnaire by: ___________________
child’s behavior.
❏ If you have any questions or concerns about your child or
❏ Answer questions based on your child’s usual behavior, about this questionnaire, contact: ____________________
not behavior when your child is sick, very tired, or hungry.
❏ Thank you and please look forward to filling out another
❏ Caregivers who know the child well and spend more than ASQ:SE-­2 in _________ months.
15–­20 hours per week with the child should complete ASQ:SE-­2.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

1. Does your child look at you when you talk to him?

☐z ☐v ☐x ◯v _____

2. Does your child cling to you more than you expect?

☐x ☐v ☐z ◯v _____

3. Does your child talk or play with adults she knows well?
☐z ☐v ☐x ◯v _____

4. When upset, can your child calm down within 15 minutes?

☐z ☐v ☐x ◯v _____

5. Does your child like to be hugged or cuddled?

☐z ☐v ☐x ◯v _____

6. Does your child seem too friendly with strangers?

☐x ☐v ☐z ◯v _____

7. Does your child settle himself down after exciting activities?

☐z ☐v ☐x ◯v _____

8. Does your child cry, scream, or have tantrums for long periods of
time?
☐x ☐v ☐z ◯v _____

TOTAL POINTS ON PAGE _____

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48 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

9. Is your child interested in things around her,

such as people, toys, and foods?
☐z ☐v ☐x ◯v _____

10. Does your child stay dry during the day?

☐z ☐v ☐x ◯v _____

11. Does your child have eating problems? For example, does he
stuff food, vomit, eat things that are not food, or ________?
☐x ☐v ☐z ◯v _____

(Please describe.)

____________________________________________________________

____________________________________________________________

12. Do you and your child enjoy mealtimes together?

☐z ☐v ☐x ◯v _____

13. Does your child do what you ask her to do?

☐z ☐v ☐x ◯v _____

14. Does your child seem happy?

☐z ☐v ☐x ◯v _____

15. Does your child sleep at least 8 hours in a 24-­hour period?

☐z ☐v ☐x ◯v _____

16. Does your child seem more active than other children his age?
☐x ☐v ☐z ◯v _____

17. Does your child use words to tell you what she wants or needs?
☐z ☐v ☐x ◯v _____

18. Does your child stay with activities he enjoys for at least
10 minutes (other than watching shows or videos, or playing with
☐z ☐v ☐x ◯v _____

electronics)?

19. Does your child use words to describe her feelings and the
feelings of others? For example, does she say, “I’m happy,”
☐z ☐v ☐x ◯v _____

“I don’t like that,” or “She’s sad?”

TOTAL POINTS ON PAGE _____

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48 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

20. Does your child move from one activity to the next with little
difficulty (for example, from playtime to mealtime)?
☐z ☐v ☐x ◯v _____

21. Does your child explore new places, such as a park or a friend’s
home?
☐z ☐v ☐x ◯v _____

22. Does your child do things over and over and get upset when you
try to stop him? For example, does he rock, flap his hands, spin,
☐x ☐v ☐z ◯v _____

or ________? (Please describe.)

____________________________________________________________

____________________________________________________________

23. Does your child hurt herself on purpose?

☐x ☐v ☐z ◯v _____

24. Does your child follow rules at home or at child care?

☐z ☐v ☐x ◯v _____

25. Does your child destroy or damage things on purpose?

☐x ☐v ☐z ◯v _____

26. Does your child stay away from dangerous things, such as fire and
moving cars?
☐z ☐v ☐x ◯v _____

27. Can your child name a friend?

☐z ☐v ☐x ◯v _____

28. Does your child show concern for other

people’s feelings? For example, does he
☐z ☐v ☐x ◯v _____

look sad when someone is hurt?

29. Do other children like to play with your child?

☐z ☐v ☐x ◯v _____

TOTAL POINTS ON PAGE _____

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48 Month Questionnaire 2 Check the box that best describes your child’s behavior.
Also, check the circle if the behavior is a concern.

CHECK IF
OFTEN OR SOME- RARELY OR THIS IS A
ALWAYS TIMES NEVER CONCERN

30. Does your child like to play with other children?

☐z ☐v ☐x ◯v _____

31. Does your child try to hurt other children, adults, or animals (for
example, by kicking or biting)?
☐x ☐v ☐z ◯v _____

32. Does your child show an unusual interest in or knowledge of

sexual language and activity?
☐x ☐v ☐z ◯v _____

33. Does your child wake three or more times during the night?
☐x ☐v ☐z ◯v _____

34. Is your child too worried or fearful? If “sometimes” or “often or

always,” please describe:
☐x ☐v ☐z ◯v _____

____________________________________________________________

____________________________________________________________

____________________________________________________________

35. Does your child have simple back-­and-­forth conversations with

you? For example,
☐z ☐v ☐x ◯v _____

Parent: “It’s raining!”

Child: “And cold outside.”
Parent: “Let’s get your coat.”
Child: “I got it!”

36. Has anyone shared concerns about your child’s behaviors? If

“sometimes” or “often or always,” please explain:
☐x ☐v ☐z ◯v _____

____________________________________________________________

____________________________________________________________

____________________________________________________________

TOTAL POINTS ON PAGE _____

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48 Month Questionnaire 2

OVERALL Use the space below for additional comments.

37. Do you have concerns about your child’s eating, sleeping, or toileting habits?
If yes, please explain: ◯ YES ◯ NO
___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

38. Does anything about your child worry you? If yes, please explain: ◯ YES ◯ NO
___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

39. What do you enjoy about your child?

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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