Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

By completing this questionnaire, you are giving your consent to allow our staff to review the ASQ-SE 2, send the results to your e-mail, and share an electronic copy of the results with the Help Me Grow, and OC Developmental Screening Registry. As our gift, you will also receive a free admission ticket to Pretend City Children's Museum so you can continue playing and learning with your child. If we have any questions about your child's ASQ-SE 2, we will contact you by phone at the number you provided.

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.