Name *

First Name

Last Name

Your age or your child. *

Please indicate your age range. Or if this is for your child, please tick their age range.

0-2

3-4

5-8

9-12

13-18

18-29

30-40

41-50

50+

Male or Female *

Male

Female

Thinks analytically all the time.

Yes

No

Has difficulty modeling someone else's behavior, but can do as told.

Yes

No

Often misses the gist of the story.

Yes

No

Always the last to get a joke.

Yes

No

Gets stuck in a set behavior; can't let go.

Yes

No

Engages in risky activites

Yes

No

Lack social tact and/or is antisocial and/or socially isolated.

Yes

No

Poor time management; often late.

Yes

No

Disorganized.

Yes

No

Problem paying attention.

Yes

No

Is hyperactive/impulsive.

Yes

No

Has obsessive thoughts or behaviors.

Yes

No

Argues all the time and is generally uncooperative.

Yes

No

Appears bored, aloof, and abrupt.

Yes

No

Considered strange by other children.

Yes

No

Immature for age.

Yes

No

Inability to form friendships.

Yes

No

Inability to share enjoyment, interests, or achievements with other people.

Yes

No

Acts inappropriately silly or giddy.

Yes

No

Has inappropriate social interaction (one-sided interaction).

Yes

No

Talks incessantly and asks repetitive questions or repeats words.

Yes

No

Had difficulty as a child getting your attention (didn't point to get you to look at or get something).

Yes

No

Did not look at self in the mirror as a toddler.

Yes

No

Procrastinates.

Yes

No

Extremely shy, especially around strangers.

Yes

No

Very good at non-verbal communication.

Yes

No

Is well-liked by other children and teachers.

Yes

No

Does not have any behavioral problems at school.

Yes

No

Understands social rules.

Yes

No

Poor self-esteem, especially when it comes to academics.

Yes

No

Hates doing homework.

Yes

No

Very good at social interaction.

Yes

No

Makes good eye contact.

Yes

No

Likes to be around people and enjoys going to parties.

Yes

No

Doesn't like to go to sleepovers.

Yes

No

Not good at following routines.

Yes

No

Can't follow multiple-step directions.

Yes

No

Seems to be very in touch with feelings.

Yes

No

Jumps to conclusions.

Yes

No

Very aware of own clothes and personal appearance.

Yes

No

Sensitive to other's feelings and their own. Doesn't want to upset other people.

Yes

No

Self-conscious; feels he is being made fun of by others.

Yes

No

Generally very easygoing attitude.

Yes

No

Likes to look at self in mirror.

Yes

No

Difficult to motivate at times.

Yes

No