rosepediatrics.com

                                                                       Ages & Stages Questionnaire

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!



(put "0" if not premature)

ROSE PEDIATRICS TREATMENT CONSENT AND DISCLOSURE

I hereby voluntarily agree to developmental screening procedures which may be performed on my child, under the general or special instructions of the attending practitioner’s care and service, or the practitioner’s designee(s).  I further understand that the practice of medicine is not an exact science and that no guarantees can be made as a result of treatment at Rose Pediatrics.  I understand that my attending practitioner encourages me to ask questions and voice concerns about medical care or services and that asking questions and voicing concerns will not compromise my care.

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.