Pediatric Autism Evaluation Questionnaire
Please complete this questionnaire to assist in the early evaluation of autism spectrum characteristics in your child.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please rate how often the following behaviors are observed in your child:
*
Rows
Never
Rarely
Sometimes
Often
Always
Responds to their name being called
1
2
3
4
5
Maintains eye contact during interactions
6
7
8
9
10
Engages in pretend play
11
12
13
14
15
Repeats words or phrases (echolalia)
16
17
18
19
20
Displays repetitive movements (e.g., hand flapping, rocking)
21
22
23
24
25
Shows interest in peers
26
27
28
29
30
Becomes upset with changes in routine
31
32
33
34
35
Lines up objects or toys
36
37
38
39
40
Has unusual sensitivity to sounds or textures
41
42
43
44
45
Does your child have any delays in speech or language development?
*
Yes
No
Not Sure
Has your child ever lost any previously acquired language or social skills?
*
Yes
No
Not Sure
Does your child have any known medical conditions? If yes, please specify.
Is there any additional information or concerns you would like to share about your child?
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