Social Communication Questionnaire
A screening questionnaire helps measure the degree of autism spectrum disorder
Name of the Evaluator
First Name
Last Name
Clinic/Institution
Title
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please answer the following screening questions.
Rows
YES
NO
N/A
NOTES
1. Poor eye contact
1
2
3
2. Responding when called by name
4
5
6
3. Scared of loud noise
7
8
9
4. Preferring being alone
10
11
12
5. Lack of curiosity
13
14
15
6. No facial expressions
16
17
18
7. Hyperactivity
19
20
21
8. Ignoring pain
22
23
24
9. Being very sensitive to a crowd
25
26
27
10. Inappropriate emotions
28
29
30
11. Difficulty in expressing needs
31
32
33
12. Forgetting words or sentences
34
35
36
13. Misunderstanding basic instructions
37
38
39
14. Clumsy body posture
40
41
42
15. Attachment to unusual objects
43
44
45
16. Being a slow learner
46
47
48
17. Lack of interest
49
50
51
18. Spinning objects or self
52
53
54
19. Drooling
55
56
57
20. Harming self
58
59
60
Additional comments, suggestions or concerns.
Referral needed?
Yes
No
Referred to
First Name
Last Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinic/Institution
Title
Date of Evaluation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator's Signature
Submit
Should be Empty: