AutismName of the Child *Contact Number *Gender and Previous Diagnosis *Date of Birth *1. Does your child enjoy being swung, bounced on your knee, etc.?YesNo2. Does your child take an interest in other children?YesNo5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or Yes No pretend other things?YesNo3. Does your child like climbing on things, such as up stairs?YesNo4. Does your child enjoy playing peek-a-boo/hide-and-seek?YesNo6. Does your child ever use his/her index finger to point, to ask for something?YesNo7. Does your child ever use his/her index finger to point, to indicate interest in something?YesNo8. Can your child play properly with small toys (e.g. cars or blocks) without just mouthing, fiddling, or dropping them?YesNo9. Does your child ever bring objects over to you (parent) to show you something?YesNo10. Does your child look you in the eye for more than a second or two?YesNo11. Does your child ever seem oversensitive to noise? (e.g., plugging ears)YesNo12. Does your child smile in response to your face or your smile?YesNo13. Does your child imitate you? (e.g., you make a face-will your child imitate it?)YesNo14. Does your child respond to his/her name when you call?YesNo15. If you point at a toy across the room, does your child look at it?YesNo16. Does your child walk?YesNo17. Does your child look at things you are looking at?YesNo18. Does your child make unusual finger movements near his/her face?YesNo19. Does your child try to attract your attention to his/her own activity?YesNo20. Have you ever wondered if your child is deaf?YesNo21. Does your child understand what people say?YesNo22. Does your child sometimes stare at nothing or wander with no purpose?YesNo23. Does your child look at your face to check your reaction when faced with something unfamiliar?YesNoI. RELATING TO PEOPLE - 24.1.0 No evidence of difficulty or abnormality in relating to people. The child's behavior is appropriate for his or her age. Some shyness, fussiness of annoyance at being told what to do may be observed, but not to an atypical degree1.52.0 Mildly abnormal relationships. The child may avoid looking the adult in the eye, avoid the adult, or become fussy if interaction is forced, be excessively shy, not be as responsive to the adult as typical, or cling to parents somewhat more than most children of the same age.2.53.0 Moderately abnormal relationships. The child shows aloofness(seems unaware of adults) at times. Persistent and forceful attempts are necessary to get the child's attention at times. Minimal contact is initiated by the child.3.54.0 Severely abnormal relationships. The child is constantly aloof or unaware of what the adult is doing. He or she almost never responds or initiates contact with the adult. Only the most persistent attempts to get the child's attention have any effect.II. IMITATION - 25.1.0 Appropriate imitation. The child can imitate sounds, words, and movements which are appropriate for his or her skill level1.52.0 Mildly abnormal imitation. The child imitates simple behaviors such as clapping or single verbal sounds most of the time: occasionally, imitates only after prodding or a delay2.53.0 Moderately abnormal imitation. The child imitates only part of the time and requires a great deal of persistence and help from the adult; frequently imitates only after a delay.3.54.0 severely abnormal imitation. The child rarely or never imitates sounds, words, or movements even with prodding and assistance.III. EMOTIONAL RESPONSE - 26.1.0 Age-appropriate and situation-appropriate responses. The child shows the appropriate type and degree of emotional response as indicated by a change in facial expression, posture, and manner1.52.0 Mildly abnormal emotional responses. The child occasionally displays a somewhat inappropriate type or degree of emotional response. Reactions are sometimes unrelated to the objects or event surrounding them2.53.0 Moderately abnormal emotional responses. The child shows definite signs of inappropriate type and/or degree of emotional response. Reactions may be quite inhibited or excessive and unrelated to the situation; may grimace, laugh, or become rigid even though no apparent emotion producing objects or events are present.3.54.0 Severely abnormal emotional responses. Responses are seldom appropriate to the situation; once the child gets in a certain mood, it is very difficult to change the mood. Conversely, the child may show wildly different emotions when nothing has changed.IV. BODY USE - 27.1.0 Age appropriate body use. The child moves with the same ease, agility, and coordination of a normal child of the same age1.52.0 Mildly abnormal body use. Some minor peculiarities may be present, such as clumsiness, repetitive movements, poor coordination or the rare appearance of more unusual movements.2.53.0 Moderately abnormal body use. Behaviors that are clearly strange or unusual for a child of this age may include strange finger movements, peculiar finger or body posturing, staring, picking at the body, self-directed aggression, rocking, spinning, or toe walking.3.54.0 Severely abnormal body use. Intense of frequent movements of the type listed above are signs of severely abnormal body use. The behaviors may persist despite attempts to discourage them or involve the child in other activities.V. OBJECT USE - 28.1.0 Appropriate use of, and interest in, toys and other objects. The child shows normal interest in toys and other objects appropriate for his or her skill level and uses these toys in appropriate ways.1.52.0 Mildly inappropriate use of, and interest in, toys and other objects. The child may show atypical interest in a toy or play with it in an inappropriate, childish way (e.g. banging or sucking on the toy).2.53.0 Moderately inappropriate use of, and interest in, toys and other objects. The child may show little interest in toys or other objects, or he may be preoccupied with using an object or toy in some strange way. He or she may focus on some insignificant part of the toy, be come fascinated with light reflection off the object, repetitively move some part of the object, or play with the object exclusively.3.54.0 Severely inappropriate use of, and interest in, toys and other objects. The child may engage in the same behaviors as above with greater frequency and intensity. The child is difficult to distract when engaged in these inappropriate activities.VI. ADAPTATION TO CHANGE - 29.1.0 Age appropriate responses to change. While the child may notice or comment on change in routines, he or she accepts these changes without undue distress.1.52.0 Mildly abnormal age appropriate responses to change. When an adult tries to change tasks, the child may continue the same activity or use the same materials2.53.0 Moderately abnormal age appropriate responses to change. The child actively resists changes in routine, tries to continue the old activity, and is difficult to distract. He or she may become angry and unhappy when an established routine is altered.3.54.0 Severely abnormal age appropriate responses to change. The child shows sever reactions to change. If a change is forced, he or she may become extremely angry or uncooperative and respond with tantrumsVII. VISUAL RESPONSE- 30.1.0 The child's visual behavior is normal and appropriate for that age. Vision is used together with the other senses as a way to explore a new object.1.52.0 Mildly abnormal visual response. The child must be occasionally reminded to look at objects. The child may be more interested in looking at mirrors or lighting than peers, may occasionally stare off into space, or may avoid looking people in the eye2.53.0 Moderately abnormal visual response. The child must be reminded frequently to look at what he or she is doing. He or she may stare off into space, avoid looking people in the eye, look at objects from an unusual angle, or hold objects very close to the eyes.3.54.0 Severely abnormal visual response. The child consistently avoids looking at people or certain objects and may show extreme forms of other visual peculiarities described aboveVIII. LISTENING RESPONSE- 31.1.0 Age appropriate listening responses. The child's listening behavior is normal and appropriate for age. Listening is used together with the other senses.1.52.0 Mildly abnormal listening responses. There may be some lack of response, or mild overreaction to certain sounds. Responses to sounds may be delayed, and sounds may need repetition to catch the child's attention. The child may be distracted by extraneous sounds2.53.0 Moderately abnormal listening responses. The child's responses to sounds vary; often ignores a sound the first few times it is made; may be startled or cover ears when hearing some everyday sounds3.54.0 Severely abnormal listening responses. The child overreacts and/or underreacts to sounds to an extremely marked degree, regardless of the type of sound.IX. TASTE, SMELL, TOUCH RESPONSE AND USE 32.1.0 Normal use of, and response to taste, smell, and touch. The child explores new objects in an age appropriate manner, generally by feeling or looking. Taste or smell may be used when appropriate. When reacting to minor everyday pain, the child expresses discomfort but does not overreact1.52.0 Mildly abnormal use of, and responses to, taste, smell, and touch. The child may persist in putting objects in his or her mouth; may smell or taste inedible objects; may ignore or overreact to mild pain that a normal child would express only discomfort.2.53.0 Moderately abnormal use of, and responses to, taste, smell, and touch. The child may be moderately preoccupied with touching, smelling, or tasting objects or people. The child may react too much or too little3.54.0 Severely abnormal use of, and responses to, taste, smell, and touch. The child is preoccupied with smelling, tasting, and feeling objects more for the sensation than for normal exploration or use of the objects. The child may completely ignore pain or react very strongly to slight discomfortsX. FEAR OR NERVOUSNESS 33.1.0 Normal fear or nervousness. The child's behavior is appropriate both to the situation and to his or her age1.52.0 Mildly abnormal fear or nervousness. The child occasionally shows too much or too little fear or nervousness compared to the reactions of a normal child of the same age and similar situation.2.53.0 Moderately abnormal fear or nervousness. The child shows either quite a bit more or quite a bit less fear than is typical for even a child younger or older in a similar situation3.54.0 Severely abnormal fear or nervousness. Fears persist even after repeated experience with harmless events or objects. It is extremely difficult to calm or comfort the child. The child may, conversely, fail to show appropriate regard for the hazards other children of the same age avoidXI. VERBAL COMMUNICATION 34.1.0 normal verbal communication, age and situation appropriate1.52.0 Mildly abnormal verbal communication. Speech shows overall retardation. Most speech is meaningful; however, some echolalia or pronoun reversal may occur. Some peculiar words or jargon may be used occasionally2.53.0 Moderately abnormal verbal communication. Speech may be absent. When present, verbal communication may be a mixture of some meaningful communication and some peculiar speech such as jargon, echolalia, or pronoun reversal. Peculiarities in meaningful speech may include excessive questioning or preoccupation with particular topics.3.54.0 Severely abnormal verbal communication. Meaningful speech is not used. The child may make infantile squeals, weird or animal-like sounds, complex noises approximating speech, or may show persistent, bizarre use of some recognizable words or phrasesXII. NON-VERBAL COMMUNICATION 34.1.0 Normal use of nonverbal communication, age and situation appropriate1.52.0 Mildly abnormal use of nonverbal communication. Immature use of nonverbal communication; may only point vaguely, or reach for what he or she wants, in same situations where the same-age child may point or gesture more specifically to indicate what he or she wants2.53.0 Moderately abnormal use of nonverbal communication. The child is generally unable to express needs or desires nonverbally, and cannot understand the nonverbal communication of others3.54.0 Severely abnormal use of nonverbal communication. The child only uses bizarre or peculiar gestures which have no apparent meaning, and shows no awareness of the meanings associated with the gestures or facial expressions of othersXIII. ACTIVITY LEVEL 351.0 Normal activity level for age and circumstances. The child is neither more active nor less active than a normal child of the same age in a similar situation.1.52.0 Mildly abnormal activity level. The child may either be mildly restless or somewhat "lazy" and slow moving at times. The child's activity level interferes only slightly with his or her performance2.53.0 Moderately abnormal activity level. The child may be quite active and difficult to restrain. He or she may have boundless energy or may not go to sleep readily at night. Conversely, the child may be quite lethargic, and need a great deal of prodding to get him or her to move about.3.54.0 Severely abnormal activity level. The child exhibits extremes of activity or inactivity and may even shift from one extreme to the other.XIV. LEVEL AND CONSISTENCY OF INTELLECTUAL RESPONSE 361.0 Intelligence is normal and reasonably consistent across various areas. The child is as intelligent as typical children of the same age and does not have any unusual intellectual skills or problems1.52.0 Mildly abnormal intellectual functioning. The child is not as smart as typical children of the same age; skills appear fairly evenly across all areas.2.53.0 Moderately abnormal intellectual functioning. In general, the child is not as smart as typical children of the same age; however, the child may function nearly normally in one or more intellectual areas3.54.0 Severely abnormal intellectual functioning. While the child generally is not as smart as the typical child of the same age, he or she may function even better than the normal child of the same age in one or more areas..XIV. GENERAL IMPRESSION 371.0 No Autism: The child shows none of the symptoms characteristic of autism1.52.0 Mild Autism. The child shows only a few symptoms or only a mild degree of autism2.53.0 Moderate autism. The child shows a number of symptoms or a moderate degree of autism3.54.0 Severe autism. the child shows many symptoms or an extreme degree of autismCalculations - MChatCalculations - MChat - CriticalCalculations - C A R S -Send MessageSave as DraftPlease do not fill in this field.
