Symptom Questionnaire Form

Please check the most accurate answer. If your child has never had the symptom, check Never. If your child has had the symptom in the past BUT NOT currently (over 6 months ago), only check Past (not now) but do not select an option under current. If your child has had the symptom in the last 6 months, only check the best option under Current (rarely, sometimes, often).

Please Note: You will not be able to save your progress, so please complete this questionnaire in one sitting. This form may take 30-45 minutes to complete.

DSA1

Has your child ever or does your child currently struggle with social interactions including any of the following:

= Currently

Approaches people in unusual ways (e.g. licks others, hugs strangers)?

Does not respond to others when his/her name is called?

Does not initiate conversations with others?

Engages in one-sided conversations (e.g. talks excessively about own interests)?

Does not understand social cues?

Does not share interests with others?

Fails to show excitement or pleasure when interacting with others?

Does not comfort or show affection to others?

Resists or lacks interest in affection from others?

Communicates with others primarily to get his/her needs?

DSA2

Has your child ever or does your child currently have difficulties with different aspects of social communication including any of the following:

= Currently

Poor eye contact (e.g. looks away when speaking to someone or being spoken to)?

Stares blankly at others when being spoken to?

Does not use gestures to communicate (e.g. nodding/shaking head, waving)?

Talks loudly, very fast, very slow, or with odd inflexion (e.g. pronounces words oddly, speaks like robot)?

Shows limited range of facial expressions?

Does not appear to understand others' emotions?

Does not use gestures (or very limited) when speaking?

DSA3

Has your child ever or does your child currently have problems with developing and maintaining relationships appropriate for his/her age:

= Currently

Does not understand what a friendship really is?

Fails to understand when others are not interested in something that he/she is doing or talking about?

Asks questions or makes statements that are socially inappropriate?

Does not understand when or why others are upset with or tease him/her?

Shows limited interest in making friends?

Is overly rigid or passive in social interactions (e.g. always wants things his/her way, goes along with everything that others want)?

DSA4

Has your child ever or does your child currently exhibit odd behavior including any of the following:

= Currently

Very formal language (e.g. like an adult or "little professor ")?

Repeats words, phrases, or songs (immediately or after a delay)?

Makes mistakes with pronouns (e.g. says "You" instead of "I")?

Makes repetitive sounds, squeals, or humming?

Makes odd motor movements (e.g. hand flapping, rocking, spinning)?

Lines up toys or objects?

Plays with toys in odd way (e.g. not in the way that toy was intended and not imaginative)?

Repeats behaviors (e.g. turning lights on/off, opening/closing doors)?

DSA5

Has your child ever or does your child currently exhibit rigid patterns of behavior including any of the following:

= Currently

Insists on following specific routines (e.g. puts clothes on same way, putting toys away)?

Insists on odd routines (e.g. turning in circle before entering a room)?

Has difficulty when routines are changed (e.g. becomes very upset or refuses to comply)?

Follows rules rigidly and becomes upset if rules are not followed by others?

DSA6

Has your child ever or does your child currently exhibit intense interests in specific objects or activities including any of the following:

= Currently

Obsessed with particular objects, toys or topics?

Is a perfectionist (e.g. things must be perfectly organized)?

Is overly interested in unusual objects (e.g. vacuum cleaners, batteries)?

Has odd fears (e.g. people wearing earrings)?

DSA7

Has your child ever or does your child currently exhibit difficulties with sensory processing including any of the following:

= Currently

Has high pain tolerance?

Does not like to be touched?

Does not like certain textures (e.g. jeans, mushy food)?

Seems very interested in watching items spin or move repetitively?

Seems afraid of or very upset by sounds (e.g. vacuum, toilet flushing)?

AIA

Has your child ever or does your child currently struggle with any of the following areas of attention:

= Currently

Fails to give close attention to details or makes careless mistakes in schoolwork or during other activities (e.g. overlooks or misses details, word is inaccurate)?

Has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, conversations, or lengthy reading)?

Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g. starts tasks but quickly loses focus and is easily sidetracked)?

Has difficulty organizing tasks and activities (e.g. difficulty managing sequential tasks, difficulty keeping materials and belongings in order, messy, disorganized work, has poor time management, fails to meet deadlines)?

Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework)?

Loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)?

Is easily distracted by extraneous stimuli?

Is forgetful in daily activities (e.g. doing chores, running errands)?

AHI

Has your child ever or does your child currently struggle with any of the following areas of hyperactivity/impulsivity:

= Currently

Fidgets with or taps hands or feet or squirms in seat?

Leaves seat in situations when remaining seated is expected (e.g. leaves his/her place in the classroom or in other situations that require remaining in place)?

Runs about or climbs in situations where it is inappropriate?

Is unable to play or engage in leisure activities quietly?

Is "on the go", acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, may be experienced by others as being restless or difficult to keep up with)?

Talks excessively?

Blurts out an answer before a question has been completed (e.g. completes people's sentences, cannot wait for turn in conversation)?

Has difficulty waiting his/her turn (e.g. while waiting in line)?

Interrupts or intrudes on others (e.g. butts into conversations, games, or activities may start using other people's things without asking or receiving permission)?

DDO

Has your child ever or does your child currently exhibit any of the following areas of emotional and behavioral regulation:

= Currently

Loses his or her temper?

Is touchy or easily annoyed?

Is angry and resentful?

Argues with authority figures or with adults?

Actively defies or refuses to comply with requests from authority figures or with rules?

Deliberately annoys others?

Blames others for his or her mistakes or misbehavior?

Has been spiteful or vindictive?

DMD

Has your child ever or does your child currently exhibit any of the following mood problems?:

= Currently

Has severe and recurring temper outbursts (e.g. verbal or physical aggression)?

Is typically in an irritable mood?

DC

Has your child ever or does your child currently exhibit any of the following areas of conduct problems:

= Currently

Bullies, threatens, or intimidates others?

Initiates physical fights?

Has been physically cruel to animals?

Has deliberately destroyed others' property (other than fire setting)?

Lies?

Has stolen items from others?

Has run away from home?

EBQ

Has your child ever or does your child currently exhibit any of the following problems:

= Currently

Touches things for no apparent reason?

Drags his/her fingers along walls or objects?

Excessively touches or hugs people?

Smells people or objects for no apparent reason?

Touches self inappropriately (e.g. private parts) at home or in public?

Licks people or inedible objects?

Spits on self or others for no apparent reason?

Excessively imitates the sounds of others?

Touches others inappropriately (e.g. breasts, buttocks)?

Excessively puts objects (e.g. shirt, toys) in mouth (not for eating)?

Blurts out socially inappropriate statements?

Rubs objects on his/her body?

Likes to be touched or caressed excessively?

Hugs others inappropriately tight?

Invades others' personal space?

Rams self into objects or people?

XNA

Has your child ever or does your child currently exhibit any of the following problems with anxiety:

= Currently

Worries?

Is fearful in social situations?

Is afraid to try new things?

PED

Has your child ever or does your child currently exhibit any of the following problems with depression:

= Currently

Thinks about or has made threats to kill him/herself?

Has mood swings?

Is tearful/crying?

Is sad?

SLE

Has your child ever or does your child currently exhibit any sleep problems:

= Currently

Has sleep problems (eg. trouble falling asleep/staying asleep, or sleeps too much)?

YSP

Has your child ever or does your child currently exhibit any of the following problems:

= Currently

Has thoughts that others would think are very strange?

Sees or hears things that others do not see or hear?

CIT

Has your child ever or does your child currently exhibit any of the following motor problems:

= Currently

Makes repeated simple motor movements (e.g. eye blinking, shoulder shrugging, open eyes wide, scrunches face/mouth)?

Makes repeated jerking or twitching movements (eg. twitching head to one side, touching shoulder to chin)?

Makes repeated noises (e.g. throat clearing, grunting, animal noises)?

IMP

For each item, please select a rating from 0 to 7.

0 = No Problem.
7 = Extreme problem.

 

How do your child's problems affect his/her relationships with peers?

How do your child's problems affect his/her relationship with parents/caregivers?

How do your child's problems affect his/her siblings?

How do your child's problems affect his/her self-esteem?

How do your child's problems affect his/her academic progress?

How do your child's problems affect his/her relationship with teacher(s)?

For the question(s) below, please use the following scale:

0 = No Problem; No need for treatment
7 = Definite Problem; Significant need for treatment

 

What is the overall severity of your child's problems?