Autism Questionnaire

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AUTISTIC INDIVIDUAL
AGE
ADDRESS
CITY
STATE
ZIP
NAME OF PERSON FILLING OUT QUESTIONNAIRE
PHONE

SECTION A

	Please explain any “yes” responses in the space provided below each question
1.	Any problems with the pregnancy?	Yes No
2.	Any difficulty with the birth?	Yes No
3.	Any serious illness or disease?	Yes No
4a.	Please list medications that are presently being taken:
4b.	Has your child had frequent infections, especially ear infections, which have been treated with broad spectrum antibiotics?	Yes No
4c.	Has your child had frequent infections with or without treatment with antibiotics?	Yes No
5.	Any food sensitivities?	Yes No
	Foods that cause problems talking, thinking or sitting still:
	Foods that cause fatigue or lethargy:
	Foods that cause stomachaches:
	Foods that cause headaches:
	Other problems:
6.	Any sensitivity to certain smells such as hair sprays, perfumes, or detergents?	Yes No
7.	Any problems if a meal is skipped?
	Headaches Dizzy Moody Stomachaches Active Tired Shaky Irritable	Other
8.	Any problems going to sleep or staying asleep?	Yes No
9.	Sensitivity to certain clothing, fabrics, or textures?	Yes No
10.	Difficulty or resists wearing tight clothing?	Yes No
11.	Reacts negatively or is sensitive to certain sounds?	Yes No
12.	Is touch painful or bothersome?	Yes No
13.	Check the stimuli that appear bothersome, painful or aversive:
	Smells Sounds Touch Lights Patterns Textures	Other
14.	Check the stimuli which have a “mesmerizing” effect:
	Lights Colors Patterns Sparkles Textures Spinning Moving	Other
15.	Is there a family history of autism? Relationship	Yes No
16.	Is anyone in the family light sensitive? Is anyone bothered by sunlight, glare, or does anyone prefer to wear sunglasses outside? Relationship	Yes No
17.	Does anyone in the family avoid reading or avoid reading for pleasure? Relationship	Yes No
18.	Does anyone take breaks while reading or only read magazines or newspapers rather than preferring to read for an hour or longer at a time? Relationship	Yes No
19.	Does anyone in the family have learning problems or dyslexia? Relationship	Yes No
20.	Does anyone in the family have a history of headaches or migraines related to lights or reading? Relationship	Yes No

SECTION B

	Please explain any "yes" responses in the space provided below each question
1.	Were there ever problems coloring and staying within the lines?	Yes No
2.	Were there ever problems being able to cut on a straight line?	Yes No
3.	Problems walking on straight lines on the floor?	Yes No
4.	Avoidance or trouble using revolving doors?	Yes No
5.	Difficulty or hesitation getting on or off moving things like an escalator?	Yes No
6.	Difficulty picking things up or putting them down?	Yes No
7.	Hesitation or fear going up or down stairs?	Yes No
8.	Difficulty catching balls?	Yes No
9.	Avoids automatic doors?	Yes No
10.	Acts calmer or prefers to be in dim lights?	Yes No
11.	Changes the brightness control on the TV?	Yes No
12.	Plays with the color control setting on the TV?	Yes No
13.	Squirms or becomes overactive under fluorescent lights?	Yes No
14.	Behavior changes under fluorescent lights?	Yes No
15.	Bothered by or dislikes certain colours?	Yes No
16.	Squints or closes one eye in bright light?	Yes No
17.	Likes to watch doors open and close?	Yes No
18.	Appears to stare at certain patterns or stripes?	Yes No
19.	Trips when going up/down a curb?	Yes No

SECTION C

Never

Sometimes

Often

Difficulty making eye contact?

Difficulty attending to and focusing on tasks?

Difficulty attending to toys and objects?

Stares into space?

Stares at or through people or objects?

Finger or hand stare?

Stares at lights, reflections, or changing levels of illumination?

Focuses on the background rather than on the figure?

Distracted by visual stimuli in the environment?

10.

Preoccupation with spinning, flipping, or twirling objects?

11.

Clumsy or awkward in movement?

12.

Awkward when getting on or off equipment?

13.

Falls or trips often?

14.

Holds onto people, railing, wall?

15.

Bumps into objects?

16.

Has difficulty going through doorways?

17.

Descends or ascends stairs or ramps without alternating feet?

18.

Exhibits hesitancy at stairs or ramps?

19.

Exhibits atypical responses to visual stimuli in any manner other than listed? If yes, please specify behaviors in the space provided.

Never

Sometimes

Often

Squints when asked to look at something?

Periodically blinks in a series or bout?

Looks at things in a series of short glances?

Identifies or repeats the name of something being held for viewing but does not look at it?

Shields one eye while sitting or walking?

Rubs or pushes on the eyes?

Views a scene by turning the head and appears to stare?

Looks down or up at the ceiling while walking?

Looks through fingers?

10.

Looks away from visual targets?

11.

Appears startled when approached?

12.

Startles when there is no apparent object?

13.

Widens eyes or stares when looking at things?

14.

Squirms or becomes overactive in bright lights?

15.

Sits under shady trees when outside?

16.

Preference for the lights dimmed or turned off?

17.

Picks strange colors for the computer screen or turns the brightness down?

Never

Sometimes

Often

When doing seat work or reading, does your child lose his/her place?

Does your child have trouble copying from a book?

Is copying from a chalkboard difficult?

Does your child read better from flashcards than a book?

Does your child rub his/her eyes, blink a lot, or move closer to the page when reading?

Is your child better at reading larger print?

When reading, does your child have difficulty tracking from line to line?

When reading, does your child use a finger or other marker?

When writing, is there unequal spacing between words or letters?

SECTION D

	Please explain any "yes" responses in the space provided below each question
1.	Do certain types of lights bother you?	Yes No
2.	Do lights sometimes have halos, starbursts, or colours around them?	Yes No
3.	Do you ever see little spots of brightness or colour ?	Yes No
4.	Is it difficult to look at some faces?	Yes No
5.	Do you see colours when you look at things?	Yes No
6.	Do some papers look shiny, too "white," or too bright?	Yes No
7.	Does it hurt to look at a white page?	Yes No
8.	Do things seem to be coming at you?	Yes No
9.	Is it hard to look at some stripes or patterns?	Yes No
10.	Do you dislike or are bothered by certain colours?	Yes No
11.	Do you find it easier to squint or look out of the side of your vision?	Yes No
12.	What it is like to look at people?	Yes No
13.	What is it like to look at things?	Yes No
14.	Do things around you move or change, such as: walls, stairs, wallpaper, furniture, carpet patterns?	Yes No
15.	Do things seem to appear and disappear?	Yes No
16.	Do things seem to fly apart?	Yes No
17.	Do you find it harder to understand what you see or hear in rooms that have fluorescent or bright lights?	Yes No
18.	Do you find traveling in a car at times upsetting?	Yes No
19.	Do you find it difficult to play catch with a ball?	Yes No
20.	Do you find that you have negative reactions to stairs, escalators, or driving?	Yes No
21.	Do your eyes get tired when you look at pages with print on them or read?	Yes No
22.	Does it get hard to hear?	Yes No
23.	When things become hard to look at, does it make it hard to hear?	Yes No

SECTION E

Which of the following best describe your child (Choose all that apply)

Self-Stimulatory Behaviors

Rocks body

Wags head

Rotates or twirls body

Waves or flicks finger(s) near eyes

Paces

Walks running hand along wall

Mode of Communication

Signing

One word/sign utterances

Two or three word/sign phrases

Simple sentences

Compound sentences

Complex sentences

Mechanized communication device (Specify device in space below)

SECTION F

Please describe in detail the type of problems the autistic individual for whom you are filling out this questionnaire is having which you feel could be helped by colored lenses.

The completed Autism Questionnaire and/or Colored Light Activity can be sent to the Irlen Institute, 5380 Village Road, Long Beach, CA 90808. For a fee of $28, a report will be sent indicating whether the child or adult with Autism is a candidate for Irlen Colored Filters.