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 C1. 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 D1. 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 E1. 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 Untitled NameThis field is for validation purposes and should be left unchanged.
