menu trigger
menu trigger
Home
Services
Child, Adolescents&Adult psychiatry
Psychology
For Patients
Client Portal
Insurance
Medication Refill
Forms And Notices
Telehealth
FAQ
Careers
MD
NP
Psychologist
Psychiatry residency program
Our Doctors
Contact US
Privacy Policy
Autism Spectrum Screening Questionnaire (ASSQ)
Instructions:
Please read the statement below and indicate by tapping, No, Somewhat, or Yes if this child stands out as different from other children of his/her age in the following ways:
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
1. is old-fashioned or precocious
*
No
Somewhat
Yes
#1
2. is regarded as an "eccentric professor" by the other children
*
No
Somewhat
Yes
#2
3. lives somewhat in a world of his/her own with restricted idiosyncratic intellectual interests
*
No
Somewhat
Yes
#3
4. accumulates facts on certain subjects (good rote memory) but does not really understand the meaning
*
No
Somewhat
Yes
#4
5. has a literal understanding of ambiguous and metaphorical language
*
No
Somewhat
Yes
#5
6. has a deviant style of communication with a formal, fussy, old-fashioned or "robot like" language
*
No
Somewhat
Yes
#6
7. invents idiosyncratic words and expressions
*
No
Somewhat
Yes
#7
8. has a different voice or speech
*
No
Somewhat
Yes
#8
9. expresses sounds involuntarily; clears throat, grunts, smacks, cries or screams
*
No
Somewhat
Yes
#9
10. is surprisingly good at some things and surprisingly poor at others
*
No
Somewhat
Yes
#10
11. uses language freely but fails to make adjustment to fit social contexts or the needs of different listeners
*
No
Somewhat
Yes
#11
12. lacks empathy
*
No
Somewhat
Yes
#12
13. makes naive and embarrassing remarks
*
No
Somewhat
Yes
#13
14. has a deviant style of gaze
*
No
Somewhat
Yes
#14
15. wishes to be sociable but fails to make relationships with peers
*
No
Somewhat
Yes
#15
16. can be with other children but only on his/her terms
*
No
Somewhat
Yes
#16
17. lacks best friend
*
No
Somewhat
Yes
#17
18. lacks common sense
*
No
Somewhat
Yes
#18
19. is poor at games: no idea of cooperating in a team, scores "own goals"
*
No
Somewhat
Yes
#19
20. has clumsy, ill coordinated, ungainly, awkward movements or gestures
*
No
Somewhat
Yes
#20
21. has involuntary face or body movements
*
No
Somewhat
Yes
#21
22. has difficulties in completing simple daily activities because of compulsory repetition of certain actions or thoughts
*
No
Somewhat
Yes
#22
23. has special routines: insists on no change
*
No
Somewhat
Yes
#23
24. shows idiosyncratic attachment to objects
*
No
Somewhat
Yes
#24
25. is bullied by other children
*
No
Somewhat
Yes
#25
26. has markedly unusual facial expression
*
No
Somewhat
Yes
#26
27. has markedly unusual posture
*
No
Somewhat
Yes
#27
Scores
Submit
Copyright by Brain Health USA 2019 - 2024. All rights reserved.