Autism Questionnaire

Autism questionnaire is used in the diagnosis of autism among small children who are usually 4 months to 5 years of age. This questionnaire is the first stage of diagnosis and helps in tracking the level of developmental disorders among affected children. It  helps in deciding corrective measures for the same. Such questionnaires are addressed to guardians of the autistic child.

Sample Autism Questionnaire

Name of autistic child: ___________________________________________________________

Age:                 ___________________________________________________________

Address:            ___________________________________________________________

Name of guardian stating relationship to the child: _____________________________________

  1. Did the child face any difficult during birth or pregnancy of the mother?
  2. Does the child suffer from any frequent illness, infections or such? If so mention the medications taken?
  3. Is the child allergic to any substance or food?
  4. Does the child respond abnormally to light, sound or touch? If so then please list them down and elaborate on his reaction.
  5. Does anyone in your family have a history of autism or any other psychological, nervous or physical disorder? Mention their relationship to the child.
  6. Does the child react in a different way on being physically hurt? If yes, cite incidences.
  7. Does the child play simple games and mingle with other children?
  8. Any behavioral pattern that particularly bothers you the most, like pointing fingers to others?
  9. Does the child enjoy climbing over stair cases and furniture?
  10. Can he use the toilet the same way as children of his age?
  11. Does he bring small things to you and show?  Does he ever tend to draw attention towards him?
  12. Do you or others face any difficulty while communicating to the child or does he make any unusual gestures? Kindly explain.

Category: Health Questionnaire

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