Autism Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastBusiness / Organization *Email * Present age of child: Under 3 years oldBetween 3 and 4 years oldBetween 4 and 5 years old*Between 5 and 6 years old*Over 6 years oldIndicate child's sex: BoyGirl Indicate child's birth order and number of mother's other childrenChild is an only childChild is first born of ____ childrenChild is last born of ____ childrenChild is middle born;____ children are older and ____ are younger than this child.Foster child, or don't knowWere pregnancy and delivery normal? Pregnancy and delivery both normalProblems during both pregnancy and deliveryPregnancy troubled; routine deliveryPregnancy untroubled; problems during deliveryDon't knowWas the birth premature (birth weight under 5 lbs)? YesNoDon't knowWas the child given oxygen in the first week? YesNoDon't know Appearance of child during first few weeks after birth: Pale, delicate lookingUnusually healthy lookingAverage, don't know, or otherUnusual conditions of birth and infancy (check only one number in left-hand column): Unusual conditionsTwin birthBoth 1 and 2Normal, or don't know Concerning baby's health in first 3 months: Excellent health, no problemsRespiration (frequent infections ____ other ____)Skin (rashes ____ infection ____ allergy ____ other ____)Feeding (learning to suck ____ colic ____ vomiting ____ other ____)Elimination (diarrhea ____ constipation ____ other ____)Several of above (indicate which: 2 ____ 3 ____ 4 ____ 5 ____)Has the child been given an electroencephalogram (EEG)? Yes, it was considered normalYes, it was considered borderlineYes, it was considered abnormalNo, or don't know, or don't know results In the first year, did the child react to bright lights, bright colors, unusual sounds, etc.? Unusually strong reactionUnusually unresponsiveAverage, or don't knowDid the child behave normally for a time before his abnormal behavior began? Never was a period of normal behaviorNormal during first 6 monthsNormal during first yearNormal during first 1 1/2 yearsNormal during first 2 yearsNormal during first 3 yearsNormal during first 4-5 years(Age 4-8 months) Did the child reach out or prepares himself to be picked up when mother approached him? Yes, or I believe soNo, I don't think he didNo, definitely notDon't know Did the child rock in his crib as a baby? Yes, quite a lotYes, sometimesNo, or very littleDon't knowAt what age did the child learn to walk alone? 8-12 months13-15 months16-18 months19-24 months25-36 months37 months or later, or does not walk aloneWhich describes the change from crawling to walking? Normal change from crawling to walkingLittle or no crawling, gradual start of walkingLittle or no crawling, sudden start of walkingProlonged crawling, sudden start of walkingProlonged crawling, gradual start of walkingOther, or don't know During the child's first year, did he seem to be unusually intelligent?Suspected high intelligenceSuspected average intelligenceChild looked somewhat dullDuring the child's first 2 years, did he like to be held? Liked being picked up; enjoyed being heldLimp and passive on being heldYou could pick child up and hold it only when and how it preferredNotably stiff and awkward to holdDon't knowBefore age 3, did the child ever imitate another person? Yes, waved bye-byeYes, played pat-a-cakeYes, otherTwo or more of aboveNo, or not sureBefore age 3, did the child have an unusually good memory? Remarkable memory for songs, rhymes, TV commercials, etc., in wordsRemarkable memory for songs, music (humming only)Remarkable memory for names, places, routes, etc.No evidence for remarkable memoryApparently rather poor memoryBoth 1 and 3Both 2 and 3Did you ever suspect the child was very nearly deaf? YesNo (Age 2-4) Is child "deaf" to some sounds but hears others? Yes, can be "deaf" to loud sounds, but hear low onesNo, this is not true of him(Age 2-4) Does child hold his hands in strange postures? Yes, sometimes or oftenNo(Age 2-4) Does child engage in rhythmic or rocking activity for very long periods of time (like on rocking-horse or chair, jump chair, swing, etc.)? Yes, this is typicalSeldom does thisNot true of him(Age 2-4) Does child ever "look through" or "walk through" people, as though they weren't there? Yes, oftenYes, I think soNo, doesn't do this (Age 2-5) Does child have any unusual cravings for things to eat or chew on? Yes, salt or salty foodsYes, often chews metal objectsYes, otherYes, more than 2 aboveNo, or not sure(Age 2-4) Does child have certain eating oddities, such as refusing to drink from a transparent container, eating only hot (or cold) food, eating only one or two foods, etc.?Yes, definitelyNo, or not to any marked degreeDon't knowWould you describe your child around 3 or 4 as often seeming "in a shell," or so distant and "lost in thought" that you couldn't reach him? Yes, this is a very accurate descriptionOnce in a while he might possibly be like thatNot an accurate description (Age 2-5) Is he cuddly?Definitely, likes to cling to adultsAbove average (likes to be held)No, rather stiff and awkward to holdDon't know(Age 3-5) Does the child deliberately hit his own head? Never, or rarelyYes, usually by slapping it with his handYes, usually by banging it against someone else's legs or headYes, usually by hitting walls, floor, furniture, etc.Several of above (Age 3-5) How well physically coordinated is the child (running, walking, balancing, climbing)? Unusually gracefulAbout averageSomewhat below average, or poor (Age 3-5) Does the child sometimes whirl himself like a top?Yes, does this oftenYes, sometimesYes, if you start him outNo, he shows no tendency to whirl (Age 3-5) How skillful is the child in doing fine work with this fingers or playing with small objects? Exceptionally skillfulAverage for ageA little awkward, or very awkwardDon't know(Age 3-5) Does the child like to spin things like jar lids, coins, or coasters? Yes, often and for rather long periodsVery seldom, or never (Age 3-5) Does child show an unusual degree of skill (much better than normal child his age) at any of the following:Assembling jigsaw or similar puzzlesArithmetic computationCan tell day of week a certain date will fall onPerfect musical pitchThrowing and/or catching a ballOtherMore than one of aboveNo unusual skill, or not sure(Age 3-5) Does the child sometimes jumps up and down gleefully when pleased?Yes, this is typicalNo, or rarely (Age 3-5) Does child sometimes line things up in precise evenly-spaced rows and insist they not be disturbed?YesNoNot sure (Age 3-5) Does the child refuse to use his hands for an extended period of time? YesNoWas there a time before age 5 when the child strongly insisted on listening to music on records? Yes, insisted on only certain recordsYes, but almost any record would doLiked to listen, but didn't demand toNo special interest in records (Age 3-5) How interested is the child in mechanical objects such as the stove or vacuum cleaner? Little or no interestAverage interestFascinated by certain mechanical things(Age 3-5) How does the child usually react to being interrupted in what he is doing?Usually resists new clothesDoesn't seem to mind, or enjoys them (Age 3-5) Is child upset by certain things that are not "right" (like crack in the wall, spot on rug, books leaning in bookcase, broken rung on chair, pipe held and not smoked)? Not especiallyYes, such things upset him greatlyNot sure(Age 3-5) Does child adopt complicated "rituals" which make him very upset if not followed (like putting many dolls to bed in a certain order, taking exactly the same route between two places, dressing according to a precise pattern, or insisting that only certain words be used in a given situation)? Yes, definitelyNot sureNo (Age 3-5) Does child get very upset if certain things he is used to are changed (like furniture or toy arrangement, or certain doors which must be left open or shut)? Yes, definitelyNoSlightly true (Age 3-5) Is the child destructive? Yes, this is definitely a problemNot deliberately or severely destructiveNot especially destructive(Age 3-5) Is the child unusually physically pliable (can be led easily; melts into your arms)? YesSeems normal in this wayDefinitely not pliable (Age 3-5) Which single description, or combination of two descriptions, best characterizes the child? Hyperactive, constantly moving, changes quickly from one thing to anotherWatches television quietly for long periodsSits for long periods, staring into space, or playing repetitively with objects, without apparent purposeCombination of 1 and 2Combination of 2 and 3Combination of 1 and 3 (Age 3-5) Does the child seem to want to be liked? Yes, unusually soJust normally soIndifferent to being liked; happiest when left alone (Age 3-5) Is child sensitive and/or affectionate?Is sensitive to criticism and affectionateIs sensitive to criticism, not affectionateNot sensitive to criticism, is affectionateNot sensitive to criticism nor affectionate(Age 3-5) Is it possible to direct child's attention to an object some distance away or out a window? Yes, no special problemHe rarely sees things very far out of reachHe examines things with fingers and mouth only (Age 3-5) Do people consider the child especially attractive?Yes, very good-looking childNo, just averageFaulty in physical appearance(Age 3-5) Does the child look up at people (meet their eyes) when they are talking to him? Never, or rarelyOnly with parentsUsually does (Age 3-5) Does the child take an adult by the wrist to use adult's hand (to open door, get cookies, turn on TV, etc.)? Yes, this is typicalPerhaps, or rarelyNo(Age 3-5) Which set of terms best describes the child? Confused, self-concerned, perplexed, dependent, worriedAloof, indifferent, self-contented, remote(Age 3-5) Is the child extremely fearful?Yes, of strangers or certain peopleYes, of strangers or certain peopleYes, of 1 and 2 aboveOnly normal fearfulnessSeems unusually bold and free of fearChild ignores or is unaware of fearsome objects(Age 3-5) Does he fall or get hurt in running or climbing? Tends toward falling or injuryAverage in this wayNever, or almost never, exposes self to fallingSurprisingly safe despite active climbing, swimming, etc. (Age 3-5) Is there a problem in that the child hits, pinches, bites or otherwise injures himself or others?Yes, self onlyYes, others onlyYes, self and othersNoAt what age did the child say his first words (even if later stopped talking)? Has never used words8-12 months13-15 months16-24 months2 years-3 years3 years-4 yearsAfter 4 years oldDon't knowOn lines below list child's first six words (as well as you can remember them) (Before age 5) Did the child start to talk, then become silent again for a week or more? Yes, but later talked againYes, but never started againNo, continued to talk, or never began talking (Before age 5) Did the child start to talk, then stop, and begin to whisper instead, for a week or more? Yes, but later talked againYes, still only whispersNow doesn't even whisperNo, continued to talk, or never began talking(Age 1-5) How well could the child pronounce his first words when learning to speak, and how well could he pronounce difficult words between 3 and 5? Too little speech to tell, or other answerAverage or below average pronunciation of first words ("wabbit," etc.), and also poor at 3 to 5Average or below on first words, unusually good at 3-5Unusually good on first words, average or below at 3-5Unusually good on first words, and also at 3-5 (Age 3-5) Is the child's vocabulary (the number of things he can name or point to accurately) greatly out of proportion to his ability to "communicate" (to answer questions or tell you something)? He can point to many objects I name, but doesn't speak or "communicate."He can accurately name many objects, but not "communicate"Ability to "communicate" is pretty good--about what you would expect from the number of words he knowsDoesn't use or understand wordsWhen the child spoke his first sentences, did he surprise you by using words he had not used individually before?YesNoNot sureToo little speech to tellHow did child refer to himself on first learning to talk?"(John) fall down," or "Baby (or Boy) fall down.""Me fall down," or "I fall down""(He, Him, She, or Her) fall down""You fall down"Any combination of 1, 2, and/or 3No speech or too little speech as yet(Age 3-5) Does child repeat phrases or sentences that he has heard in the past (maybe using a hollow, parrot-like voice), what is said having little or no relation to the situation?Yes, definitely, except voice not hollow or parrot-likeYes, definitely, including peculiar voice toneNot sureNoToo little speech to tell (Before age 5) Can the child answer a simple question like "What is your first name?" or "Why did Mommy spank Billy?" Yes, can answer such questions adequatelyNo, uses speech, but can't answer questionsToo little speech to tell(Before age 5) Can the child understand what you say to him, judging from his ability to follow instructions or answer you? Yes, understands very wellYes, understands fairly wellUnderstands a little, if you repeat and repeatVery little or no understanding (Before age 5) If the child talks, do you feel he understands what he is saying?Doesn't talk enough to tellNo, he is just repeating what he has heard with hardly any understandingNot just repeating--he understands what he is saying, but not wellNo doubt that he understands what he is saying(Before age 5) Has the child used the word "Yes?" Has used "Yes" fairly often and correctlySeldom has used "Yes," but has used itHas used sentences, but hasn't used word "Yes"Has used a number of other words or phrases, but hasn't used word "Yes"Has no speech, or too little speech to tell (Age 3-5) Does the child typically say "yes" by repeating the same question he has been asked? (Example: You ask "Shall we go for a walk, Honey?" and he indicates he does want to go by saying "Shall we go for a walk, Honey" or "Shall we go for a walk?") Yes, definitely, does not say "Yes" directlyNo, would say "Yes" or "OK" or similar answerNot sureToo little speech to say (Before age 5) Has the child asked for something by using the same sentence you would use when you offer it to him? (Example: The child wants milk, so he says: "Do you want some milk?" or "You want some milk") Yes, definitelyNo, would ask differentlyNot sureNot enough speech to tell(Before age 5) Has the child used the word "I?"Has used "I" fairly often and correctlySeldom has used "I," but has used it correctlyHas used sentences, but hasn't used the word "I"Has used a number of words or phrases, but hasn't used the word "I"Has used "I," but only where the word "you" belongedHas no speech, or too little speech to tell(Before age 5) How does the child usually say "No" or refuse something? He would just say "No"He would ignore youHe would use some rigid meaningful phrase (like "Don't want it!" or "No milk!" or "No walk!")Would use phrase having only private meaning like "Daddy go in car"Other, or too little speech to tell (Before age 5) Has the child used one word or idea as a substitute for another, for a prolonged time? (Example: always says "catsup" to mean "red," or uses "penny" for "drawer" after seeing pennies in a desk drawer)Yes, definitelyNoNot sureToo little speech to tell Knowing what you do now, at what age do you think you could have first detected the child's abnormal behavior? That is, when did detectable abnormal behavior actually begin?In first 3 months4-6 months7-12 months13-24 months2 years-3 years3 years-4 yearsAfter 4th yearDid not graduate high schoolFatherMotherHigh school graduateFatherMotherPost high school tech. trainingFatherMotherSome collegeFatherMotherCollege graduateFatherMotherSome graduate workFatherMotherGraduate degreeFatherMother Indicate the child's nearest blood relatives, including parents, who have been in a mental hospital or who were known to have been seriously mentally ill or retarded. Consider parents, siblings, grandparents, uncles and auntsBefore age 2, arched back and bent head back, when held Very TrueTrueFalseBefore age 2, struggled against being held Very TrueTrueFalseAbnormal craving for certain foodsVery TrueTrueFalseEats unusually large amounts of foodVery TrueTrueFalseCovers ears at many sounds Very TrueTrueFalseOnly certain sounds seem painful to him Very TrueTrueFalseFails to blink at bright lights Very TrueTrueFalseSkin color lighter or darker than others in familyVery TrueTrueFalsePrefers inanimate (nonliving) things Very TrueTrueFalseAvoids peopleVery TrueTrueFalseInsists on keeping certain object with himVery TrueTrueFalseAlways frightened or very anxious Very TrueTrueFalseInconsolable crying Very TrueTrueFalseNotices changes or imperfections and tries to correct them Very TrueTrueFalseTidy (neat, avoids messy things) Very TrueTrueFalseHas collected a particular thing (toy horses, bits of glass, etc.)Very TrueTrueFalseAfter delay, repeats phrases he has heard Very TrueTrueFalseAfter delay, repeats whole sentences he has heardVery TrueTrueFalseRepeats questions or conversations he has heard, over and over, without variation Very TrueTrueFalseGets "hooked" or fixated on one topic (like cars, maps, death)Very TrueTrueFalseExamines surfaces with fingers Very TrueTrueFalseHolds bizarre pose or posture Very TrueTrueFalseChews or swallows nonfood objects Very TrueTrueFalseDislikes being touched or held Very TrueTrueFalseIntensely aware of odors Very TrueTrueFalseHides skill or knowledge, so you are surprised later onVery TrueTrueFalseSeems not to feel painVery TrueTrueFalseTerrified at unusual happenings Very TrueTrueFalseLearned words useless to himself Very TrueTrueFalseLearned certain words, then stopped using them Very TrueTrueFalseMessageSubmit