ASSESSMENT FORMAT FOR AUTISM SPECTRUM DISORDERS

Date of evaluation:
Demographic data: NameAge:
Sex:

Informant: Chief Complaints:

Age of onset/ Disability first noted: -

History:Birth History:
Prenatal illness of the motherH/O abortion/ miscarriage before pregnancyDuration of pregnancy: (Full term/ preterm)Type of delivery: (Normal/ C section/ Forceps)Birth cry: (Immediate/ Delayed)
Birth weight: (H/O LBW or overweight)H/O birth injury if anyH/O fever/seizures/jaundice & other disordersTreatment detailsMothers milk/ H/O oromotor abnormalities at infancy-

Developmental History:
Motor (Head control, roll over, crawling, sitting, standing, walking)H/O Speech/ motor delay if any-

Family History:
Number of family members in familyBirth order of the childPresence of consanguinityAge of parents and siblings-mother age-,father ageH/O similar illness in the familyType of Family: (Nuclear/Joint/ Separated)-

Treatment History :
Present and past therapy / treatment child underwent-

Educational History:
Educational status of the parentsEducational status of the child-

On Observation:
Postures/ physical abnormality/ sensory signs/ play skills/& others
Child likes to hold small piece of thread, paper etc
Enjoys making sound through mouth.
Likes to hug and touch others

Play History & evaluation:

Availability of play space and toysType of motivation (Intrinsic/extrinsic)Ability to manipulate toys
Play stage (solitary/ parallel/ group & cognitive developmental stages)-

Speech and language:Mode of communication - speech/ sign/ AACReceptive language skillsExpressive language skills- absent

On Examination:
Motor skills:
Gross motor:
Gait patternStair climbingJumping/ HoppingSupine flexionProne extension-

Balance & coordination skillsEquilibrium reactions / protective extensionStanding balance (Static & dynamic)Sitting balance (Static & dynamic)B/L symmetrical & Asymmetrical coordination- b/l symmetrical
Eye hand coordinationPraxis (P/O any kind of dyspraxia)-

Imitation skills:Imitates gross motor movements with sequence and repetition

imitates oral motor movement

Imitates block patternImitates action paired with soundsImitates verbal responses -

Fine motor skillsGrasp: Mass/ cylindrical/ square/ Hook-present

Reach: (At all sides in standing/ cross leg & long leg sitting)Midline crossing ReleasePinch: (tripod/ pulp to pulp/ tip to tip)-

In hand manipulation skills:

Translation (finger to palm)Rotation (simple/ complex)Shift (vertical/ horizontal)-

Cognitive Perceptual skills:

Orientation: Time, place & person Identification of parents, family members,
friends, rooms at home/school, concept of today/ tomorrow/ later/ morning/ noon/
evening/ night.Comprehension: Ability to follow commands (single step / multi step)Attention: (Visual / auditory)Concentration:Memory: Verbal& Visual (short term/ long term)Perception: (Figure ground/ colour)

Concepts:
Body parts (on self & others)Colour (Sorting to abstract of each)Size (identification to comparison)Shape (Sorting to abstract of each)Number (rote counting & number concept)-

Visual perception skills :

Visual tracking Identifying similar pictures/ pattern of designsDot joiningBlock designingPuzzle solving ( 3piece, 5piece, 8piece, etc)Design copying-

Social/ emotional skills:Social smile Eye contact maintaining and sustainingStranger identificationStranger fearPeer interaction (Spontaneous/ with prompt)Emotional comprehensionExpressions of emotionAsking for needs-present (non verbally)
Expressing likes and dislikes-present non verbal
Asking for help-present

Oromotor functions:Oral sensitivityPresence of droolingOral movements/ oral praxisBiting/ chewingBlowing/ SuckingSipping/ spitting

School readiness skills:Sitting toleranceWaits for turnSustaining and maintaining peer groupFollows instruction in a group -

Sensory Evaluation:Stereotypical/ ritualistic behaviorsGravitational insecuritySleep disturbances-

Tactile :Seem overly distressed when having his hair or fingernails / toenails
cut?Have an unusual need for touching or avoiding touching certain
surfaces or textures such as blankets, carpets, or stuffed toys?Dislike getting his hands in sand, finger paint, paste, or similar
materials?-

Proprioceptive :Seem driven to seek activities such as pushing, pulling, dragging,

lifting, and jumping?Grinds his teeth?-

Vestibular:Seek and/or tolerate movement activities such as swinging, running,

and jumping and not seem to get dizzy as readily as others? Seem to have trouble sitting upright, or tend to slouch when at a table
or desk?-

Visual:Sensitive to or bother by light, especially bright light (blinks, squints,

cries, or close eyes)?Have trouble finding an object when it is aimed a group of other
things? -

Auditory:Seem highly sensitive to noise and sometimes hear things that other
people dont hear? Seem overwhelmed or distracted by laughter, cheers, or crowds of
people speaking at the same time, such as in a restaurant? -

Olfactory / Gustatory:Gags, vomit, or complain of nausea when smelling odors such as soap,
perfume, or cleaning products?Like to taste non food items such as glue, paint etc.?-

Behavior:
Quiet / Normal / Over-Active/ Impulsive / Aggressive / Distractible /
wants attention / anxious / friendly / shy child is usually quit and friendly but
becomes impulsive followed by aggressive when restricted from activities which
gives additional tactile stimulation.

Behavior problems:
Tantrum / Maladaptive/ injurious behaviors if any-shows tantrums and
fidgety when wish is not fulfilled.

ADLs:-

Brushing:
Opening/ closing tap
Paste on brush
Cupping
Brushing
Rinsing/ spitting
Washing/ wiping

Dressing:
Upper body (donning & doffing shirt/ t shirt/ frock/ inner garments)
Lower body (donning doffing pants/ skirt/ under garments)
Buttoning/ unbuttoningZipping/ unzippingWearing shoe/ socks/ tying shoe lace-

Grooming: (if applicable)Eating:

Solid/ semi solid/ liquid (with spoon & hand)-

Toileting:
Indication of bowel/ BladderAbility to reach toilet at home independentlyAbility to clean self & commode-

Bathing:
Dressing/ Undressing
Pouring water
Ability to soap front/ back
Wipe

IADL :Knows common household items know its uses and operations like
Switches / Televisions/ Lock etc.

Other specific issues if any-