A. Information About Researcher and Project

B. Information Specific to Each ATEC/Person (Research Subject)

Assessment Period [e.g., baseline, 1 week post, 1 month post, etc.]:

Diagnosis: You may check more than one diagnosis.

Autism Asperger Syndrome PDD-NOS Landau-Kleffner Syndrome Other

If you checked 'Other,' please specify:

Last Name / First Name of Child [or identification code]:
/

Sex of Child: Male Female
Age:
Date of Birth [format: mo/da/yr; e.g., 09/25/98]:
Today's Date [same format as above]:
Form Completed By: [first and last name]
Relationship: [e.g., mother, teacher]

I. Speech/Language/Communication

N = Not true S=Somewhat true V=Very true

1. Knows own name	N	S	V
2. Responds to ‘No’ or ‘Stop’	N	S	V
3. Can follow some commands	N	S	V
4. Can use one word at a time	N	S	V
5. Can use 2 words at a time	N	S	V
6. Can use 3 words at a time	N	S	V
7. Knows 10 or more words	N	S	V
8. Can use sentences with 4 or more words	N	S	V
9. Explains what he/she wants	N	S	V
10. Asks meaningful questions	N	S	V
11. Speech tends to be meaningful/relevant	N	S	V
12. Often uses several successive sentences	N	S	V
13. Carries on fairly good conversation	N	S	V
14. Has normal ability to commmunicate for his/her age	N	S	V

II. Sociability

N = Not descriptive S=Somewhat descriptive V=Very descriptive

1. Seems to be in a shell - you cannot reach him/her	N	S	V
2. Ignores other people	N	S	V
3. Pays little or no attention when addressed	N	S	V
4. Uncooperative and resistant	N	S	V
5. No eye contact	N	S	V
6. Prefers to be left alone	N	S	V
7. Shows no affection	N	S	V
8. Fails to greet parents	N	S	V
9. Avoids contact with others	N	S	V
10. Does not imitate	N	S	V
11. Dislikes being held/cuddled	N	S	V
12. Does not share or show	N	S	V
13. Does not wave ‘bye bye’	N	S	V
14. Disagreeable/not compliant	N	S	V
15. Temper tantrums	N	S	V
16. Lacks friends/companions	N	S	V
17. Rarely smiles	N	S	V
18. Insensitive to other's feelings	N	S	V
19. Indifferent to being liked	N	S	V
20. Indifferent if parent(s) leave	N	S	V

III. Sensory/Cognitive Awareness

N = Not descriptive S=Somewhat descriptive V=Very descriptive

1. Responds to own name	N	S	V
2. Responds to praise	N	S	V
3. Looks at people and animals	N	S	V
4. Looks at pictures (and T.V.)	N	S	V
5. Does drawing, coloring, art	N	S	V
6. Plays with toys appropriately	N	S	V
7. Appropriate facial expression	N	S	V
8. Understands stories on T.V.	N	S	V
9. Understands explanations	N	S	V
10. Aware of environment	N	S	V
11. Aware of danger	N	S	V
12. Shows imagination	N	S	V
13. Initiates activities	N	S	V
14. Dresses self	N	S	V
15. Curious, interested	N	S	V
16. Venturesome - explores	N	S	V
17. “Tuned in” - Not spacey	N	S	V
18. Looks where others are looking	N	S	V

IV. Health/Physical/Behavior

N = Not a Problem MI=Minor Problem MO=Moderate Problem S=Serious Problem

1. Bed-wetting	N	MI	MO	S
2. Wets pants/diapers	N	MI	MO	S
3. Soils pants/diapers	N	MI	MO	S
4. Diarrhea	N	MI	MO	S
5. Constipation	N	MI	MO	S
6. Sleep problems	N	MI	MO	S
7. Eats too much/too little	N	MI	MO	S
8. Extremely limited diet	N	MI	MO	S
9. Hyperactive	N	MI	MO	S
10. Lethargic	N	MI	MO	S
11. Hits or injures self	N	MI	MO	S
12. Hits or injures others	N	MI	MO	S
13. Destructive	N	MI	MO	S
14. Sound-sensitive	N	MI	MO	S
15. Anxious/fearful	N	MI	MO	S
16. Unhappy/crying	N	MI	MO	S
17. Seizures	N	MI	MO	S
18. Obsessive speech	N	MI	MO	S
19. Rigid routines	N	MI	MO	S
20. Shouts or screams	N	MI	MO	S
21. Demands sameness	N	MI	MO	S
22. Often agitated	N	MI	MO	S
23. Not sensitive to pain	N	MI	MO	S
24. “Hooked” or fixated on certain objects/topics	N	MI	MO	S
25. Repetitive movements	N	MI	MO	S

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page last updated 5/24/04