Questionnaire for Parents

Parent SQ

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.

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Child's First Name

Child's Last Name

Date of Birth

Race

Ethnicity

Completed By

Relationship

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Does not initiate conversations with others?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Does not understand social cues?

Never

Past (not now)

Rarely

Sometimes

Often

Does not share interests with others?

Never

Past (not now)

Rarely

Sometimes

Often

Fails to show excitement or pleasure when interacting with others?

Never

Past (not now)

Rarely

Sometimes

Often

Does not comfort or show affection to others?

Never

Past (not now)

Rarely

Sometimes

Often

Resists or lacks interest in affection from others?

Never

Past (not now)

Rarely

Sometimes

Often

Communicates with others primarily to get his/her needs?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Speaks in an odd manner (e.g. pronounces words oddly, speaks like robot)?

Never

Past (not now)

Rarely

Sometimes

Often

Shows limited range of facial expressions?

Never

Past (not now)

Rarely

Sometimes

Often

Does not appear to understand others' emotions?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

DSA3

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

= Currently

Does not understand what a friendship really is?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Asks questions or makes statements that are socially inappropriate?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Shows limited interest in making friends?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Has trouble playing/talking with others if the focus of activity is not his/her interest?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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 ")?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Makes repetitive sounds, squeals, or humming?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Obsessively lines up toys or objects?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

DSA6

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

= Currently

Is obsessed with particular objects, toys or topics?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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?

Never

Past (not now)

Rarely

Sometimes

Often

Does not like to be touched?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Seems very interested in watching items spin or move repetitively?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Is easily distracted by extraneous stimuli?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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?

Never

Past (not now)

Rarely

Sometimes

Often

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Runs about or climbs in situations where it is inappropriate?

Never

Past (not now)

Rarely

Sometimes

Often

Is unable to play or engage in leisure activities quietly?

Never

Past (not now)

Rarely

Sometimes

Often

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Talks excessively?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

DDO

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

= Currently

Loses his/her temper?

Never

Past (not now)

Rarely

Sometimes

Often

Is touchy or easily annoyed?

Never

Past (not now)

Rarely

Sometimes

Often

Is angry and resentful?

Never

Past (not now)

Rarely

Sometimes

Often

Argues with authority figures or with adults?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Deliberately annoys others?

Never

Past (not now)

Rarely

Sometimes

Often

Blames others for his/ her mistakes or misbehavior?

Never

Past (not now)

Rarely

Sometimes

Often

Has been spiteful or vindictive?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Is typically in an irritable mood?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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?

Never

Past (not now)

Rarely

Sometimes

Often

Initiates physical fights?

Never

Past (not now)

Rarely

Sometimes

Often

Has been physically cruel to animals?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Lies?

Never

Past (not now)

Rarely

Sometimes

Often

Has stolen items from others?

Never

Past (not now)

Rarely

Sometimes

Often

Has run away from home?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

EBQ

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

= Currently

Touches things for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

Drags his/her fingers along walls or objects?

Never

Past (not now)

Rarely

Sometimes

Often

Excessively touches or hugs people?

Never

Past (not now)

Rarely

Sometimes

Often

Smells people or objects for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Licks people or inedible objects?

Never

Past (not now)

Rarely

Sometimes

Often

Spits on self or others for no apparent reason?

Never

Past (not now)

Rarely

Sometimes

Often

Excessively imitates the sounds of others?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Excessively puts objects in mouth (not for eating)?

Never

Past (not now)

Rarely

Sometimes

Often

Blurts out socially inappropriate statements?

Never

Past (not now)

Rarely

Sometimes

Often

Rubs objects on his/her body?

Never

Past (not now)

Rarely

Sometimes

Often

Likes to be touched or caressed excessively?

Never

Past (not now)

Rarely

Sometimes

Often

Hugs others inappropriately tight?

Never

Past (not now)

Rarely

Sometimes

Often

Invades others' personal space?

Never

Past (not now)

Rarely

Sometimes

Often

Rams self into objects or people?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

XNA

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

= Currently

Worries?

Never

Past (not now)

Rarely

Sometimes

Often

Is fearful in social situations?

Never

Past (not now)

Rarely

Sometimes

Often

Is afraid to try new things?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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 or harm him/her self?

Never

Past (not now)

Rarely

Sometimes

Often

Has mood swings?

Never

Past (not now)

Rarely

Sometimes

Often

Is tearful/crying?

Never

Past (not now)

Rarely

Sometimes

Often

Is sad?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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)?

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

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

Never

Past (not now)

Rarely

Sometimes

Often

Please provide some examples of any behaviors listed above that your child has experienced.

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 intervention | 7 = Definite Problem; Significant need for intervention