Trinity Medical Centre

1 Goldstone Villas, Hove, BN3 3AT

Telephone: 01273 736030

sxicb-bh.thetrinitymedicalcentre@nhs.net

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Child (4-11 years) Autism Screening Questionnaire

Child (4-11 years) Autism Screening Questionnaire 

This questionnaire is suitable for patients aged 4-11 years old. Please answer the questions below, rating the patient on each of the criteria.

Name(Required)
Email(Required)
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Part A

1. S/he notices small sounds when others dont
2. S/he usually concentrates more on the whole picture, rather than the small details
3. In a social group, s/he can easily keep track of several different people's conversations
4. S/he finds it easy to go back and forth between different activities
5. S/he frequently finds that s/he doesn't know how to keep a conversation going with his/her peers
6. S/he is good at social chit-chat
7. When s/he is read a story, s/he finds it difficult to work out the character's intentions or feelings
8. When s/he was in preschool, s/he used to enjoy playing games involving pretending with other children
9. S/he finds it easy to work out what someone is thinking or feeling just by looking at their face
10. S/he find it hard to make new friends

Thank you for completing the questionnaire.

Please ensure you have sent details of your chosen Right to Choose provider along with your statement to sxicb-bh.trinity-adhd.autismreferrals@nhs.net