The present study aims to explore the use of assessment in mathematics content courses for future elementary school teachers. Analysis of self assessment data on mathematical understanding and peer assessment data on oral mathematical presentation showed that pre-service teachers had a balanced understanding of procedural knowledge and problem solving. Conceptual understanding was not in the structure of pre-service teachers' mathematical knowledge. Understandings of conceptual knowledge, procedural knowledge, and problem solving had no meaningful effects on gains in mathematics performance. Aspects of oral mathematical presentation were associated with improved understanding of procedural knowledge and in particular conceptual knowledge. The result of the study calls for a conceptual approach to mathematical knowledge and sufficient mathematical problem solving in college-level mathematics content courses and in particular the infusion of assessment into college-level mathematics education for pre-service teachers.