Autism Screening Intake (Prototype)

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Age of the girl

Numeric between 1 and 15 both inclusive

Is there a family history of autism or related neurodevelopmental conditions?

0–No, 1–Not Sure, 2–Yes

Did you experience any complications during pregnancy or childbirth?

0–No complications, 1–Any complications reported

At what age did your child first start to walk?

Numeric between 1 and 5 both inclusive

At what age did your child first start to speak in full words or phrases?

Numeric between 1 and 5 both inclusive

Are there any known medical, neurological, or psychological conditions your child is currently experiencing?

0–None, 1–One or more conditions

Appears comfortable in social settings (e.g., classrooms, birthday parties)

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Prefers spending time with close friend(s) over group of people with group activities

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Seems emotionally or physically exhausted after socializing

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Confidently initiates conversations

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Struggles to read facial expressions, tone, or body language

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Recognizes familiar people when seeing them unexpectedly

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Is able to put up with / go along with inaccuracies / guestimations / approximation?

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Frequently feels misunderstood during conversations

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Becomes upset or frustrated when misunderstood

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Struggles to express emotions with words

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Finds it difficult to calm down after becoming upset or stressed

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Demonstrates ritualized patterns of verbal or nonverbal behavior with extreme distress at small changes (Prefers routines in daily life)

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Rehearses or plans their conversations (phrases, always greet Good Morning/Evening, etc.) in advance

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Monitors others' reactions to her actions to get a validation that she is acting appropriately

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Engages in "stimming" i.e. certain repetitive movements or actions: Twirling, rocking, waving hands, wiggling legs, humming, etc.

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Appears confused by social expectations or 'unwritten rules'

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Mimics others' behavior to fit in

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Avoids or struggles to maintain eye contact

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Fnds it difficult to follow multiple conversations happening at once (e.g., in a group setting)?

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Feels overwhelmed by the need to communicate in social situations?

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Feels overwhelmed / stressed when something changes on them at the last minute or gets upset when others do not follow through on plans/promises made

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Appears anxious or withdrawn in unfamiliar social settings

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Finds it difficult to manage emotions during stressful interactions

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Internalizes anxiety or stress without showing it

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Struggles to follow conversations in group settings

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Sensitive to loud noises and/or bright lights or visual clutter

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Avoids certain fabrics or textures due to discomfort

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Affected by strong smells that others seem to tolerate

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Appears overwhelmed in crowded or noisy environments

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Uses the same phrases or greetings in different situations

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

Demonstrates strong emotional reactions in intense situations (e.g., anger, crying, withdrawal)

1–Never, 2–Rarely, 3–Sometimes, 4–Often, 5–Always

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