ASD Assessment (4 - 11 years)
If you are a concerned parent/caregiver who suspects your child may be showing signs of developmental delay or a neurodevelopmental disorder such as an Autism Spectrum Disorder, complete this questionnaire. Your responses will be used to assist us with determining whether you seek further evaluation. Check each box that pertains to your child.
Instructions: Please read the following questions carefully, and select the most appropriate answer as it relates to your child. All responses are confidential.
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Rows
Yes
No
1. Does s/he join in playing games with other children easily?
2. Does s/he come up to you spontaneously for a chat?
3. Was s/he speaking by 2 years old?
4. Does s/he enjoy sports?
5. Is it important to him/her to fit in with the peer group?
6. Does s/he appear to notice unusual details that
others miss?
7. Does s/he tend to take things literally?
8. When s/he was 3 years old, did s/he spend a lot of time pretending (e.g., play-acting being a superhero, or holding teddy’s tea parties)?
9. Does s/he like to do things over and over again, in the same way all the time?
10. Does s/he find it easy to interact with other children?
11. Can s/he keep a two-way conversation going?
12. Can s/he read appropriately for his/her age?
13. Does s/he mostly have the same interests as his/her peers?
14. Does s/he have an interest which takes up so much time that s/he does little else?
15. Does s/he have friends, rather than just acquaintances?
16. Does s/he often bring you things s/he is interested in to show you?
17. Does s/he enjoy joking around?
18. Does s/he have difficulty understanding the rules for polite behaviour?
19. Does s/he appear to have an unusual memory for details?
20. Is his/her voice unusual (e.g., overly adult, flat, or very monotonous)?
21. Are people important to him/her?
22. Can s/he dress him/herself?
23. Is s/he good at turn-taking in conversation?
24. Does s/he play imaginatively with other children, and engage in role-play?
25. Does s/he often do or say things that are tactless or socially inappropriate?
26. Can s/he count to 50 without leaving out any numbers?
27. Does s/he make normal eye-contact?
28. Does s/he have any unusual and repetitive movements?
29. Is his/her social behaviour very one-sided and always on his/her own terms?
30. Does s/he sometimes say “you” or “s/he” when s/he means “I”?
31. Does s/he prefer imaginative activities such as play-acting or story-telling, rather than numbers or lists of facts?
32. Does s/he sometimes lose the listener because of not explaining what s/he is talking about?
33. Can s/he ride a bicycle (even if with stabilisers)?
34. Does s/he try to impose routines on him/herself, or on others, in such a way that it causes problems?
35. Does s/he care how s/he is perceived by the rest of the group?
36. Does s/he often turn conversations to his/her favourite subject rather than following what the other person wants to talk about?
37. Does s/he have odd or unusual phrases?
38. Have teachers/health visitors ever expressed any concerns about his/her development?
39. Has s/he ever been diagnosed with any of the following: Language Delay, ADHD, hearing or visual difficulties, Autism Spectrum Disorder (ASD) or a physical disability?
In relation to #39 above, check all that apply:
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ADHD
ASD
Hearing Impairment
Language Delay
Physical Impairment
Visual Impairment
N/A
Other
Child's Birthdate
*
Child's Birthdate
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Child's Gender
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Male
Female
Which insurance company is your child enrolled with?
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Email
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example@example.com
Name
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First Name
Last Name
Phone Number
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-
Area Code
Phone Number
How would you prefer to be contacted?
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Phone
Email
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