Gender: MaleFemaleOther

Is (s)he verbal?: YesNoAlmostOther

Is (s)he mainstreamed at school?: YesNoOther

Does (s)he wear glasses?: YesNoContacts

Full siblings without ASD diagnosis?: YesNo

Age relative to ASD sibling(s)?: OlderYoungerBoth

 

 

Please rate how true each statement is (once for each child); and what
a priority the issue is for you (how much effort or resources you would
devote to help your child with that challenge). "5" is truest/highest.

 

My child does not look me/other people in the eye enough:
True: 12345        Priority: 12345

My child struggles to understand emotions:
True: 12345        Priority: 12345

My child finds it difficult to focus/concentrate:
True: 12345        Priority: 12345

My child finds it hard to speak to us (communicate verbally):
True: 12345        Priority: 12345

My child does not look when I call his/her name:
True: 12345        Priority: 12345

My child does not smile or express warmth toward us:
True: 12345        Priority: 12345

My child finds it hard to understand what we say:
True: 12345        Priority: 12345

My child has an issue controlling frustration:
True: 12345        Priority: 12345

My child has an issue with tantrums and meltdowns:
True: 12345        Priority: 12345

My child often "stims" in a visible way:
True: 12345        Priority: 12345

My child often makes surprising vocalizations:
True: 12345        Priority: 12345

My child often speaks either too loudly or too softly:
True: 12345        Priority: 12345

My child often uses inappropriate words or phrases:
True: 12345        Priority: 12345

My child often says or reveals things (s)he shouldn't to strangers:
True: 12345        Priority: 12345

My child often talks over others or doesn't know when others want to speak:
True: 12345        Priority: 12345

My child often speaks either too much or too little in a conversation:
True: 12345        Priority: 12345

My child seems bothered by sudden or loud noises:
True: 12345        Priority: 12345

My child seems bothered by bright or flashing lights:
True: 12345        Priority: 12345

My child uses phrases from TV/movies/etc rather than his own words:
True: 12345        Priority: 12345

My child gets picked on or bullied at school or elsewhere:
True: 12345        Priority: 12345

Challenges related to autism cause tension in my marriage or relationships:
True: 12345        Priority: 12345

Challenges of autism have caused me to be unhappy, depressed or hopeless:
True: 12345        Priority: 12345

My child sometimes wanders off unexpectedly:
True: 12345        Priority: 12345

I fear that my child will be harmed or lost when wandering:
True: 12345        Priority: 12345

My child has difficulty understanding sarcasm:
True: 12345        Priority: 12345

My child has difficulty understanding tone of voice:
True: 12345        Priority: 12345