Autism Questionnaire

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AUTISTIC INDIVIDUAL
AGE
ADDRESS
CITY
STATE
ZIP
NAME OF PERSON FILLING OUT QUESTIONNAIRE
PHONE
Answer these questions for the individual for whom you are filling out this questionnaire.
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
4. List medications that are presently being taken:
4a. Has your child had frequent infections, especially ear infections, which have been treated with broad spectrum antibiotics?
- Yes
- No
4b. Has your child had frequent infections with or without treatment with antibiotics?
- Yes
- No
5. Environmental allergies? If "yes," please explain below.
- Yes
- No
Explain.
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
- Patterns
- Textures
- Colors
- Sparkles
- Spinning
- Moving
Other
15. Is there a family history of autism?
- Yes
- No
Relationship
16. Is anyone in the family light sensitive? Is anyone bothered by sunlight, glare, headlights/street lights at night, or wear sunglasses outside?
- Yes
- No
Relationship
17. Does any family member prefer to read for less than an hour at a time or only read magazines or newspapers?
- Yes
- No
Relationship
18. Does any family member get strain, fatigue, or tired from reading?
- Yes
- No
Relationship
19. Does anyone in the family have reading problems, ADD, or dyslexia?
- Yes
- No
Relationship
20. Does anyone in the family have a history of headaches or migraines related to lights or reading?
- Yes
- No
Relationship
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. Difficulty riding a bike?
- Yes
- No
9. Difficulty riding a bike?
- Yes
- No
10. Needs prompt to go down stairs?
- Yes
- No
11. Avoids automatic doors?
- Yes
- No
12. Acts calmer or prefers to be in dim lights?
- Yes
- No
13. Changes the brightness control on the TV?
- Yes
- No
14. Plays with the color control setting on the TV?
- Yes
- No
15.Squirms or becomes overactive under fluorescent lights?
- Yes
- No
16. Behavior changes under fluorescent lights?
- Yes
- No
17. Bothered by or dislikes certain colors?
- Yes
- No
18. Squints or closes one eye in bright light?
- Yes
- No
19. Likes to watch doors open and close?
- Yes
- No
SECTION C
1. Difficulty making eye contact?
- Never
- Sometimes
- Often
2. Difficulty attending to and focusing on tasks?
- Never
- Sometimes
- Often
3. Difficulty attending to toys and objects?
- Never
- Sometimes
- Often
4. Stares into space?
- Never
- Sometimes
- Often
5. Stares at or through people or objects?
- Never
- Sometimes
- Often
6. Finger or hand stare?
- Never
- Sometimes
- Often
7. Stares at lights, reflections, or changing levels of illumination?
- Never
- Sometimes
- Often
8. Focuses on the background rather than on the figure?
- Never
- Sometimes
- Often
9. Distracted by visual stimuli in the environment?
- Never
- Sometimes
- Often
10. Preoccupation with spinning, flipping, or twirling objects?
- Never
- Sometimes
- Often
11. Clumsy or awkward in movement?
- Never
- Sometimes
- Often
12. Awkward when getting on or off equipment?
- Never
- Sometimes
- Often
13. Falls or trips often?
- Never
- Sometimes
- Often
14. Holds onto people, railing, wall?
- Never
- Sometimes
- Often
15. Bumps into objects?
- Never
- Sometimes
- Often
16. Has difficulty going through doorways?
- Never
- Sometimes
- Often
17. Descends or ascends stairs or ramps without alternating feet?
- Never
- Sometimes
- Often
18. Exhibits hesitancy at stairs or ramps?
- Never
- Sometimes
- Often
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
SECTION D
1. Squints when asked to look at something?
- Never
- Sometimes
- Often
2. Periodically blinks in a series or bout?
- Never
- Sometimes
- Often
3. Looks at things in a series of short glances?
- Never
- Sometimes
- Often
4. Identifies or repeats the name of something being held for viewing but does not look at it?
- Never
- Sometimes
- Often
5. Shields one eye while sitting or walking?
- Never
- Sometimes
- Often
6. Rubs or pushes on the eyes?
- Never
- Sometimes
- Often
7. Views a scene by turning the head and appears to stare?
- Never
- Sometimes
- Often
8. Looks down or up at the ceiling while walking?
- Never
- Sometimes
- Often
9. Looks through fingers?
- Never
- Sometimes
- Often
10. Looks away from visual targets?
- Never
- Sometimes
- Often
11. Appears startled when approached?
- Never
- Sometimes
- Often
12. Startles when there is no apparent object?
- Never
- Sometimes
- Often
13. Widens eyes or stares when looking at things?
- Never
- Sometimes
- Often
14. Squirms or becomes overactive in bright lights?
- Never
- Sometimes
- Often
15. Sits under shady trees when outside?
- Never
- Sometimes
- Often
16. Preference for the lights dimmed or turned off?
- Never
- Sometimes
- Often
17. Picks strange colors for the computer screen or turns the brightness down?
- Never
- Sometimes
- Often
SECTION E
1. When doing seat work or reading, does your child lose his/her place?
- Never
- Sometimes
- Often
2. Does your child have trouble copying from a book?
- Never
- Sometimes
- Often
3. Is copying from a chalkboard difficult?
- Never
- Sometimes
- Often
4. Does your child read better from flashcards than a book?
- Never
- Sometimes
- Often
5. Does your child rub his/her eyes, blink a lot, or move closer to the page when reading?
- Never
- Sometimes
- Often
6. Is your child better at reading larger print?
- Never
- Sometimes
- Often
7. When reading, does your child have difficulty tracking from line to line?
- Never
- Sometimes
- Often
8. When reading, does your child use a finger or other marker?
- Never
- Sometimes
- Often
9. When writing, is there unequal spacing between words or letters?
- Never
- Sometimes
- Often
SECTION D

Please explain any "yes" responses in the space provided below each question
1. Bothered by bright or fluorescent lights?
- Yes
- No
2. Do lights sometimes have halos, starbursts, or colours around them?
- Yes
- No
3. See little spots of brightness or colour ?
- Yes
- No
4. Is it difficult to look at faces?
- Yes
- No
5. See colours when looking at things?
- Yes
- No
6. Do white pages look shiny, too "white," or 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. Dislikes or bothered by certain colours?
- Yes
- No
11. Squints or looks out of the side of your vision?
- Yes
- No
12. Is it difficult to look at people?
- Yes
- No
13. Is it difficult to look at things?
- Yes
- No
14. Do things appear to 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. Is it harder to understand what is seen or heard in rooms that have fluorescent or bright lights?
- Yes
- No
18. Is traveling in a car at times upsetting?
- Yes
- No
19. Is it difficult to play catch with a ball?
- Yes
- No
20. Negative reactions to stairs, escalators, or driving?
- Yes
- No
21. Eyes feel tired when looking at pages with print on them or reading?
- 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 $35, a report will be sent indicating whether the child or adult with Autism is a candidate for Irlen Colored Filters.
Enter your email address in the space provided and click “Submit” to receive a copy of your test that you can print out and mail to the Irlen Institute for evaluation.*
Enter Email Confirm Email
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