Questionnaire (6 to 18 Year Old)
Child
*
First Name
Last Name
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person Completing Form
*
First Name
Last Name
Relationship to Child
*
Email
example@example.com
Back
Next
During the past four weeks, how often did your child…
Rows
Never
Rarely
Occasionally
Frequently
Very Frequently
appear disorganized?
become bothered by some fabrics or tags in clothes?
seek the company of other children?
show little emotion?
follow instructions that he/she understood?
argue and fight with other children?
have problems waiting his/her turn?
share fun activities with others?
look at others when talking with them?
engage in tasks that require sustained effort?
avoid looking at people who spoke to him/her?
play with toys appropriately?
have a strong reaction to any change in routine?
have trouble talking with other children?
understand the point of view of others?
learn simple tasks but then forget them quickly?
use language that was immature for his/her age?
get into trouble with adults?
have social problems with children of the same age?
use an odd way of speaking?
repeat certain words or phrases out of context?
become obsessed with details?
keep a conversation going?
insist on doing things the same way each time?
overreact to touch?
repeat or echo what others said?
smell, taste, or eat inedible objects?
understand how someone else felt?
overreact to common smells?
become distracted?
play with others?
notice social cues?
respond when spoken to by adults?
avoid looking at an adult when there was a problem?
have problems paying attention when doing homework or chores?
make careless mistakes in schoolwork?
talk too much about things that adults don’t care about?
resist being touched or held?
care about what other people think or feel?
focus too much on details?
not understand why others don’t like him/her?
share his/her enjoyment with others?
show an interest in the ideas of others?
leave homework or chores unfinished?
understand age-appropriate humor or jokes?
flap his/her hands when excited?
listen when spoken to?
focus on one subject for too much time?
need things to happen just as expected?
talk too much about things that other children don’t care about?
insist on certain routines?
have problems paying attention to fun tasks?
become fascinated with parts of objects?
line up objects in a row?
smile appropriately?
start conversations with others?
fail to complete tasks?
ask questions that were off topic?
have trouble talking with adults?
interrupt or intrude on others?
look at others when interacting with them?
overreact to loud noises?
become upset if routines were changed?
choose to play alone?
insist on keeping certain objects with him/her at all times?
have social problems with adults?
twirl, spin, or bang objects?
reverse pronouns (e.g., you for me)?
show good peer interactions?
respond when spoken to by other children?
appear fidgety when asked to sit still?
Submit
Should be Empty: