Autism Questionnaire

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Autism Questionnaire

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Demographics

Child's Gender

Male Female

Child's Age:

1. Does your child enjoy being swung, bounced on your knee, etc?

Yes No

2. Does your child take an interest in other children?

Yes No

3. Does your child like climbing on things like stairs?

Yes No

4. Does your child enjoy playing peek-a-boo or hide-and-seek?

Yes No

5. Does your child ever pretend to talk on the phone, take care of a doll or pretend other things?

Yes No

6. Does your child ever use their index finger to point to ask for something?

Yes No

7. Does your child ever use their index finger to point at something to show they are interested in it?

Yes No

8. Can your child play properly with small toys like cars or blocks without just putting them in their mouths, dropping them or fiddling with them?

Yes No

9. Does your child ever bring objects over to you to show you something?

Yes No

10. Does your child look you in the eye for more than a second or two?

Yes No

11. Does your child smile in response to your face or your smile?

Yes No

12. Does your child imitate you (like making the same face after you make one)?

Yes No

13. Does your child respond to their name when you call?

Yes No

14. If you point at a toy across the room, does your child look at it?

Yes No

15. Does your child walk?

Yes No

16. Does your child look at things you are looking at?

Yes No

17. Does your child try to attract your attention to their own activity?

Yes No

18. Does your child seem to hear well?

Yes No

19. Does your child understand what people say?

Yes No

20. Does your child look at your face to check your reaction when faced with something unfamiliar?

Yes No

21. Does your child understand what people say?

Yes No

22. Does your child sometimes stare at nothing or wander around with no purpose?

Yes No

23. Does your child look at your face to check your reaction when faced with something unfamiliar?

Yes No

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