ASSQ Autism Spectrum Screening Questionnaire (6-17 years)

Name of Child

First NameLast Name

Date of Birth

Date

Gender

Who completed the answers?

First NameLast Name

Relationship to Child

Email address (that you would like the results sent to)

example@example.com

Address

Street Address

Street Address Line 2

CityCounty

Post code

Phone Number

Area CodePhone Number

Date of completion

Date

This child stands out as different from other children of his/her age in the following way

	No (0)	Somewhat (1)	Yes (2)
1. Is old-fashioned or precocious
2. Is regarded as an ”eccentric professor” by the other children
3. Lives somewhat in a world of his/her own with restricted idiosyncratic intellectual interests
4. Accumulates facts on certain subjects (good rote memory) but does not really understand the meaning
5. Has literal understanding of ambiguous and metaphorical language
6. Has a deviant style of communication with a formal, fussy, old-fashioned or “robot-like” language
7. Invents idiosyncratic (peculiar/individual) words and expressions.
8. Has a different voice or speech
9. Expresses sounds involuntarily; clears throat, grunts, smacks, cries or screams
10. Is surprisingly good at some things and surprisingly poor at others
11. Uses language freely but fails to make adjustment to fit social contexts or the needs of different listeners
12. Lacks empathy
13. Makes naive and embarrassing remarks
14. Has a deviant style of gaze (looks away)
15. Wishes to be sociable but fails to make relationships with peers
16. Can be with other children but only on his/her terms
17. Lacks best friend
18. Lacks common sense
19. Is poor at games: no idea of cooperating in a team, scores “own goals”
20. Has clumsy, ill coordinated, ungainly, awkward movements or gestures
21. Has involuntary face or body movements
22. Has difficulties in completing simple daily activities because of compulsory repetition of certain actions or thoughts
23. Has special routines: insists on no change
24. Shows idiosyncratic (unusual) attachment to objects
25. Is bullied by other children
26. Has markedly unusual facial expression
27. Has markedly unusual posture
28. Copies you (can be in a very discrete way)
29. Episodes of eating problems
30. No time perception
31. Too much sympathy
32. Extremely interested in pop/ rock bands, soap operas or natural disasters
33. Avoids demands
34. Very determined
35. Difficulties with choice; always avoids choosing
36. Difficulties with self-care
37. Carefree or over meticulous as regards physical appearance/dress
38. Naive
39. Comes too close to others
40. Interacts mostly with younger children
41. Engages in dangerous activities
42. Exaggeratedly fanciful
43. Talks without content
44. Writes long stories (can be in stark contrast to level of talk)
45. Acts or lives different parts (TV stars, videos, animals)

Specify reasons other than above:

ABC Mental Health Support is registered with the Information Commissioner’s Office (ICO) and fully complies with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. All personal data is collected, processed, and stored lawfully, securely, and confidentially.