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

Name *

First

Last

Business / Organization *

Email *

Indicate child's sex:

Boy
Girl

Indicate child's birth order and number of mother's other children

Child is an only child
Child is first born of ____ children
Child is last born of ____ children
Child is middle born;____ children are older and ____ are younger than this child.
Foster child, or don't know

Were pregnancy and delivery normal?

Pregnancy and delivery both normal
Problems during both pregnancy and delivery
Pregnancy troubled; routine delivery
Pregnancy untroubled; problems during delivery
Don't know

Was the birth premature (birth weight under 5 lbs)?

Yes
No
Don't know

Was the child given oxygen in the first week?

Yes
No
Don't know

Appearance of child during first few weeks after birth:

Pale, delicate looking
Unusually healthy looking
Average, don't know, or other

Unusual conditions of birth and infancy (check only one number in left-hand column):

Unusual conditions
Twin birth
Both 1 and 2
Normal, or don't know

Concerning baby's health in first 3 months:

Excellent health, no problems
Respiration (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 normal
Yes, it was considered borderline
Yes, it was considered abnormal
No, 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 reaction
Unusually unresponsive
Average, or don't know

Did the child behave normally for a time before his abnormal behavior began?

(Age 4-8 months) Did the child reach out or prepares himself to be picked up when mother approached him?

Yes, or I believe so
No, I don't think he did
No, definitely not
Don't know

Did the child rock in his crib as a baby?

Yes, quite a lot
Yes, sometimes
No, or very little
Don't know

Which describes the change from crawling to walking?

Normal change from crawling to walking
Little or no crawling, gradual start of walking
Little or no crawling, sudden start of walking
Prolonged crawling, sudden start of walking
Prolonged crawling, gradual start of walking
Other, or don't know

During the child's first year, did he seem to be unusually intelligent?

Suspected high intelligence
Suspected average intelligence
Child looked somewhat dull

During the child's first 2 years, did he like to be held?

Liked being picked up; enjoyed being held
Limp and passive on being held
You could pick child up and hold it only when and how it preferred
Notably stiff and awkward to hold
Don't know

Before age 3, did the child have an unusually good memory?

Remarkable memory for songs, rhymes, TV commercials, etc., in words
Remarkable memory for songs, music (humming only)
Remarkable memory for names, places, routes, etc.
No evidence for remarkable memory
Apparently rather poor memory
Both 1 and 3
Both 2 and 3

Did you ever suspect the child was very nearly deaf?

(Age 2-4) Is child "deaf" to some sounds but hears others?

Yes, can be "deaf" to loud sounds, but hear low ones
No, this is not true of him

(Age 2-4) Does child hold his hands in strange postures?

Yes, sometimes or often
No

(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 typical
Seldom does this
Not true of him

(Age 2-4) Does child ever "look through" or "walk through" people, as though they weren't there?

Yes, often
Yes, I think so
No, doesn't do this

(Age 2-5) Does child have any unusual cravings for things to eat or chew on?

(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, definitely
No, or not to any marked degree
Don't know

Would 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 description
Once in a while he might possibly be like that
Not an accurate description

(Age 2-5) Is he cuddly?

Definitely, likes to cling to adults
Above average (likes to be held)
No, rather stiff and awkward to hold
Don't know

(Age 3-5) Does the child deliberately hit his own head?

Never, or rarely
Yes, usually by slapping it with his hand
Yes, usually by banging it against someone else's legs or head
Yes, 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 graceful
About average
Somewhat below average, or poor

(Age 3-5) Does the child sometimes whirl himself like a top?

Yes, does this often
Yes, sometimes
Yes, if you start him out
No, 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 skillful
Average for age
A little awkward, or very awkward
Don't know

(Age 3-5) Does the child like to spin things like jar lids, coins, or coasters?

Yes, often and for rather long periods
Very 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:

(Age 3-5) Does the child sometimes jumps up and down gleefully when pleased?

Yes, this is typical
No, or rarely

(Age 3-5) Does child sometimes line things up in precise evenly-spaced rows and insist they not be disturbed?

Yes
No
Not sure

(Age 3-5) Does the child refuse to use his hands for an extended period of time?

Was there a time before age 5 when the child strongly insisted on listening to music on records?

Yes, insisted on only certain records
Yes, but almost any record would do
Liked to listen, but didn't demand to
No 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 interest
Average interest
Fascinated by certain mechanical things

(Age 3-5) How does the child usually react to being interrupted in what he is doing?

Usually resists new clothes
Doesn'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 especially
Yes, such things upset him greatly
Not 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, definitely
Not sure
No

(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, definitely
No
Slightly true

(Age 3-5) Is the child destructive?

Yes, this is definitely a problem
Not deliberately or severely destructive
Not especially destructive

(Age 3-5) Is the child unusually physically pliable (can be led easily; melts into your arms)?

Yes
Seems normal in this way
Definitely 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 another
Watches television quietly for long periods
Sits for long periods, staring into space, or playing repetitively with objects, without apparent purpose
Combination of 1 and 2
Combination of 2 and 3
Combination of 1 and 3

(Age 3-5) Does the child seem to want to be liked?

Yes, unusually so
Just normally so
Indifferent to being liked; happiest when left alone

(Age 3-5) Is child sensitive and/or affectionate?

Is sensitive to criticism and affectionate
Is sensitive to criticism, not affectionate
Not sensitive to criticism, is affectionate
Not 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 problem
He rarely sees things very far out of reach
He examines things with fingers and mouth only

(Age 3-5) Do people consider the child especially attractive?

Yes, very good-looking child
No, just average
Faulty in physical appearance

(Age 3-5) Does the child look up at people (meet their eyes) when they are talking to him?

Never, or rarely
Only with parents
Usually 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 typical
Perhaps, or rarely
No

(Age 3-5) Which set of terms best describes the child?

Confused, self-concerned, perplexed, dependent, worried
Aloof, indifferent, self-contented, remote

(Age 3-5) Is the child extremely fearful?

Yes, of strangers or certain people
Yes, of strangers or certain people
Yes, of 1 and 2 above
Only normal fearfulness
Seems unusually bold and free of fear
Child ignores or is unaware of fearsome objects

(Age 3-5) Does he fall or get hurt in running or climbing?

Tends toward falling or injury
Average in this way
Never, or almost never, exposes self to falling
Surprisingly 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 only
Yes, others only
Yes, self and others
No

On 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 again
Yes, but never started again
No, 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 again
Yes, still only whispers
Now doesn't even whisper
No, 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 answer
Average or below average pronunciation of first words ("wabbit," etc.), and also poor at 3 to 5
Average or below on first words, unusually good at 3-5
Unusually good on first words, average or below at 3-5
Unusually 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 knows
Doesn't use or understand words

When the child spoke his first sentences, did he surprise you by using words he had not used individually before?

Yes
No
Not sure
Too little speech to tell

How 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 3
No 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?

(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 adequately
No, uses speech, but can't answer questions
Too 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 well
Yes, understands fairly well
Understands a little, if you repeat and repeat
Very 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 tell
No, he is just repeating what he has heard with hardly any understanding
Not just repeating--he understands what he is saying, but not well
No doubt that he understands what he is saying

(Before age 5) Has the child used the word "Yes?"

Has used "Yes" fairly often and correctly
Seldom has used "Yes," but has used it
Has 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" directly
No, would say "Yes" or "OK" or similar answer
Not sure
Too 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, definitely
No, would ask differently
Not sure
Not enough speech to tell

(Before age 5) Has the child used the word "I?"

Has used "I" fairly often and correctly
Seldom has used "I," but has used it correctly
Has 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" belonged
Has 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 you
He 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, definitely
No
Not sure
Too 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?

Did not graduate high school

Father
Mother

High school graduate

Father
Mother

Post high school tech. training

Father
Mother

Some college

Father
Mother

College graduate

Father
Mother

Some graduate work

Father
Mother

Graduate degree

Father
Mother

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 aunts

Before age 2, arched back and bent head back, when held

Very True
True
False

Before age 2, struggled against being held

Very True
True
False

Abnormal craving for certain foods

Very True
True
False

Eats unusually large amounts of food

Very True
True
False

Covers ears at many sounds

Very True
True
False

Only certain sounds seem painful to him

Very True
True
False

Fails to blink at bright lights

Very True
True
False

Skin color lighter or darker than others in family

Very True
True
False

Prefers inanimate (nonliving) things

Very True
True
False

Avoids people

Very True
True
False

Insists on keeping certain object with him

Very True
True
False

Always frightened or very anxious

Very True
True
False

Inconsolable crying

Very True
True
False

Notices changes or imperfections and tries to correct them

Very True
True
False

Tidy (neat, avoids messy things)

Very True
True
False

Has collected a particular thing (toy horses, bits of glass, etc.)

Very True
True
False

After delay, repeats phrases he has heard

Very True
True
False

After delay, repeats whole sentences he has heard

Very True
True
False

Repeats questions or conversations he has heard, over and over, without variation

Very True
True
False

Gets "hooked" or fixated on one topic (like cars, maps, death)

Very True
True
False

Examines surfaces with fingers

Very True
True
False

Holds bizarre pose or posture

Very True
True
False

Chews or swallows nonfood objects

Very True
True
False

Dislikes being touched or held

Very True
True
False

Intensely aware of odors

Very True
True
False

Hides skill or knowledge, so you are surprised later on

Very True
True
False

Seems not to feel pain

Very True
True
False

Terrified at unusual happenings

Very True
True
False

Learned words useless to himself

Very True
True
False

Learned certain words, then stopped using them

Very True
True
False

Name