Autism assessment

This is a compact version of the autism assessment appointment checklist, without the boxes to fill in or the graphics:

How to use this checklist

• Use the ‘Understanding your child checklist’ on page 14 to help you fill this checklist in.
• Use the boxes to make further notes.
• Write down everything you can think of that applies, even if there isn’t a question about the topic.

Appointment checklist

Your child’s name:
Child’s date of birth:    /   / 
Child’s age:   Years   Months
Date of appointment:      /   /
Appointment with:
Your name:
Phone number:
email address:

“Tell me about your concerns”

How would you describe your concerns? What are the five key words or phrases you would use?

Use this space for other notes and reminders. If someone else has raised a concern, use this space to summarise who it was and what they said.

How old was your child when you first started to notice things that concerned you?     Years     Months

Looking back from the birth of your child until now, is there anything about their development that stands out in your memory?

Think about milestones such as crawling, walking and eating solid foods. Think also about things that might have stood out about their sleep or weaning.

“Tell me about your child’s sleep”

What time does your child normally go to sleep at night and wake up in the morning?
Sleep    Wake up    Total hours

If your child sleeps during the day, what time do they sleep?
Sleep    Wake up    Total hours

How easy is it for your child to go to sleep?
Very ….. Can take …..  Finds it 
easy       a while       really hard

How often does your child wake in the night?

Rarely …. Occasionally ….  Every
                                      night

How has sleep been in general since they were a baby?

   Calm …… Not always ..… Troubled
and happy      easy             sleeper

Use some space for any other notes about your child’s sleep.

“Tell me about how your child talks and communicates”

Are there things you think your child should be saying or doing by now? How would you describe your main concerns:

Has anyone – a member of nursery staff or a childminder, perhaps – commented on your child’s speech?    If so, what did they say?

Does your child gaze into your eyes and are they comfortable holding eye contact?
Never  ….….  All the time

Use this space for any other notes about your child’s communication.

“Tell me about how your child plays”

How would you describe the way your child plays? What are the top five words or phrases you would use:   ‘Imaginative play’ is when a child uses their imagination to pretend to be an astronaut or a bus driver, or to pretend to do things like cook or clean for example.

How often would you say your child’s play was ‘imaginative’ in this way?    
Hardly ….. Sometimes …. All the
ever                                  time

Does your child prefer to play on their own? Will they watch other people and join in with them, such as other children, other adults or family members?     
Plays on …… Watches … Joins in
their own       others

What are the main games, toys, topics or objects that your child is most interested in?

Use this space for any other notes about how your child plays.

“Tell me about your child’s likes and dislikes”

How much does your child like routine?
Hates …………….. Loves
routine              routine

Describe their routines.

Your child might regularly do things like clicking their fingers, flapping their hands or doing repetitive movements.    Have you noticed anything like this?

If your child is angry or upset, is there anything that they do to soothe themselves?

Our senses include sight, sound and touch.    

Does your child react negatively/strongly to things such as loud noises, bright lights or sensations like something being wet?    Or do they ever seem not to notice or react to these things when others do?

Describe how they respond to sensory input.

“How well does your child eat?”

Very fussy ……….…… Enjoys
    eater                    eating

Prefers …………..… Enjoys lots
one food        of different foods

What they like to eat for breakfast:
What they like to eat for lunch:
What they like to eat for dinner:
What snacks they eat throughout the day?
The foods they like:
The foods they don’t like:

“Tell me about you, your child and your family”

Were there any complications or difficulties during pregnancy or birth?

Where was your child born?

Use this space for any further notes about the pregnancy and the birth.

Did the mother take any medication during pregnancy?
Yes    No

How long did the pregnancy last?   Months    Days

Your health

How has your health been since your child’s birth?

Not so ……………  Feeling
good                    great

Do you have any ongoing health problems?     If so, what are they and are you taking any regular medication?

How would you describe your mood?  

Not so ……………  Feeling
good                    great

Use this space to add some notes or more detail about what you’d like to say about your health.    You can also use this space to talk about your partner’s health if you think it is appropriate.

“Has your child had any health problems?”

This isn’t about the usual coughs and colds.   Think about things like fevers, infections, bowel problems or any other conditions.

Family history

Think in particular about anyone in your family (uncles, aunts, grandparents, your child’s brothers and sisters) who has or may have autism spectrum disorders or other developmental, mental or physical health problems, such as ADHD, a learning disability or epilepsy.

For each one, what is/was the:

Relationship       Health issue?
to your child?

Use some space for any other thoughts, observations or questions.

This is a text version of the checklist in Right from the start by Ambitious about Autism.      Better to download the original if you can.