NSA: ATEC

The following survey will ask you questions to help us serve you and/or the patient better. Depending on the individual, it takes anywhere from 5 to 15 minutes to complete this questionnaire. If you are unable to complete this, please contact us so that we might assist you.

Completion of this survey is REQUIRED to be treated by our doctors.

What best describes your relationship to the patient?

Your Name

First NameLast Name

Patient's Name

First NameLast Name

Sex

Age (in Years)

If less than one, enter 0

Speech Language and Communication

Social Score

Cognition and Awareness

Physical and Behavior

ATEC Score

NSA Total Severity

NSA Severity Score (Out of 100)

Absolute No's (Out of 33)

Please select the choice that is most appropriate pertaining to speech/language/communication:

Rows	Not Ture	Somewhat True	Very True
Knows own name
Responds to "No" or "Stop"
Can follow commands
Can use one word at a time ("No", "Eat", "Water", Etc)
Can use two words at a time ("Don't want", "Go home")
Can use three words at a time ("Want more milk")
Knows 10 words or more
Can use sentences with 4 or more words
Explains what he/she wants
Asks meaningful questions
Speech tends to be meaningful/relevant
Often uses successive sentences
Carries on fairly good conversation
Has normal ability to communicate for his/her age

Please select the choice that is most accurate pertaining to sociability

Rows	Not Descriptive	Somewhat Descriptive	Very Descriptive
Seems to be in a shell - you cannot reach him/her
Ignores other people
Pays little attention when addressed
Uncooperative and resistant
No eye contact
Prefers to be left alone
Shows no affection
Fails to greet parents
Avoids contact with others
Does not imitate
Dislikes being held or cuddled
Does not share or show
Does not wave "bye, bye"
Disagreeable/ Non-compliant
Temper tantrums
Lacks friends/companions
Rarely smiles
Insensitive to others' feelings
Indifferent to being liked
Indifferent if parent(s) leave

Please select the choice that is most accurate pertaining to sensory/cognitive awareness

Rows	Not Descriptive	Somewhat Descriptive	Very Descriptive
Responds to own name
Responds to praise
Looks at people and animals
Looks at pictures (and T.V.)
Does drawing, coloring, art
Plays with toys appropriately
Appropriate facial expression
Understands stories on T.V.
Understands explanations
Aware of environment
Aware of danger
Shows imagination
Initiates activities
Dresses self
Curious, interested
Venturesome and explores
"Tuned in", not spacey
Looks where others are looking

Please select the choice that is most accurate pertaining tohealth/physical/behavior:

Rows	Not a Problem	Minor Problem	Moderate Problem	Serious Problem
Bed-wetting
Wets pants/diapers
Soils pants/diapers
Diarrhea
Constipation
Sleep Problems
East too much/too little
Extremely limited diet
Hyperactive
Lethargic
Hits or injures self
Hits or injures others
Destructive
Sound sensitive
Anxious/Fearful
Unhappy/Crying
Seizures
Obsessive speech
Rigid routines
Shouts and screams
Demands sameness
Often agitated
Not sensitive to pain
"Hooked" or fixated on certain objects/topics
Repetitive movements (stimming, rocking, etc)

ATEC: Autism Treatment Evaluation Checklist