Pediatric Autism Early Screening Checklist
Child Information
Child's Name
Date of Birth
Age
Screening Questions
1. Does your child respond to their name when called?
Yes
No
2. Does your child make eye contact when interacting with others?
Yes
No
3. Does your child share interests or enjoyment with others?
Yes
No
4. Does your child use gestures (such as pointing) to communicate?
Yes
No
5. Does your child show repetitive behaviors (rocking, hand-flapping, etc.)?
Yes
No
6. Does your child have difficulty with changes in routine?
Yes
No
7. Does your child play with toys in unusual or repetitive ways?
Yes
No
Additional Comments