Note: #18 is a multi-choice answer where you can have more than one answer (I've highlighted that text in red). All other questions are single-choice. Please don't skip any questions because I won't really be able to use your other answers then to formulate a score. If you do have any questions about certain items, please ask and I'll try to clarify as best as possible without leading you. And if you'd like to give any feedback, that'd be welcome too.
QUOTE
The Questionnaire:
1. Rate your comfort level in social situations:
1___2___3___4___5___6___7___8___9
extremely..............................extremely
comfortable.........................uncomfortable
2. In every day situations, how much do you tend to make eye contact with the person you’re talking to?: (This means looking at the eyes, not elsewhere on the face)
1___2___3___4___5___6___7___8___9
a lot......................................none
3. Rate your level of comfort in making eye contact:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
comfortable........................uncomfortable
4. How much do you stutter when you’re anxious?
1___2___3___4___5___6___7___8___9
never....................................always
5. Rate your general, every day stress levels:
1___2___3___4___5___6___7___8___9
no stress...........................extreme stress
6. How often do you avoid things in life because of your anxiety?
1___2___3___4___5___6___7___8___9
never....................................always
7. Do you have a tendency to collect things? (e.g., stamps, cards, coins, etc.)
1___2___3___4___5___6___7___8___9
never....................................always
8. Do you have interests or passions which take up much of your time and thoughts?
1___2___3___4___5___6___7___8___9
never....................................always
9. Do you forego necessities (such as bathroom, food, sleep) when you are actively involved in these interests?
1___2___3___4___5___6___7___8___9
never....................................always
10. When talking with someone, do you tend to talk a lot about one of your special interests?
1___2___3___4___5___6___7___8___9
never....................................always
11. When talking with someone, do you tend to talk more about yourself and focus less on the other person?
1___2___3___4___5___6___7___8___9
never....................................always
12. Do you have difficulty with a change in routine, particularly change imposed upon you by another person, organization, or event?
1___2___3___4___5___6___7___8___9
never....................................always
13. When you have gotten used to doing something, do you prefer to do it the same way each consecutive time?
1___2___3___4___5___6___7___8___9
never....................................always
14. Do you have habits which you perform obsessively, such as washing your hands or checking the door locks, even though you know it isn’t necessary?
1___2___3___4___5___6___7___8___9
never....................................always
15. Would you consider yourself a perfectionist?
1___2___3___4___5___6___7___8___9
no, definitely not................a total perfectionist
16. How organized are you?
1___2___3___4___5___6___7___8___9
extremely..............................extremely
disorganized...........................organized
17. When you are having a conversation with someone, where do you tend to look?
(a) I look at the eyes
(b) I look at the eyes or I look away
© I look at the mouth
(d) I look at the mouth or I look away
(e) I don’t look at the person. I tend to look away
18. When anxious or excited, do you: (multiple selection)
(a) pace
(b) rock
© use repetitive hand gestures (such as hand flapping, finger twisting, hand wringing)
(d) vocal repetitions (such as repeating words over to yourself)
(e) use another form of self-stimulation not listed above
(f) none of the above
19. Rate the variety of your diet:
1___2___3___4___5___6___7___8___9
not limited..........................very limited
at all
20. Would you consider yourself food sensitive?
1___2___3___4___5___6___7___8___9
not sensitive.......................very sensitive
21. How often do you develop “food obsessions” in which you eat a particular type of food for a period of time (sometimes to the point of eating it for every meal)?
1___2___3___4___5___6___7___8___9
never....................................always
22. How is your balance in every day life?
1___2___3___4___5___6___7___8___9
horrible................................excellent
23. How often do you trip, fall, or run into things?
1___2___3___4___5___6___7___8___9
never....................................always
24. How often you find it difficult to find clothes which feel comfortable to you? (not otherwise due to weight, body structure, or finances)
1___2___3___4___5___6___7___8___9
never....................................always
25. How sound sensitive do you consider yourself? (i.e., you find various sounds uncomfortable or painful)
1___2___3___4___5___6___7___8___9
not sensitive.........................extremely
at all...................................sensitive
26. Do you feel overwhelmed and overstimulated in noisy, crowded environments?
1___2___3___4___5___6___7___8___9
never....................................always
27. How light sensitive do you consider yourself? (i.e., you find various visual stimuli, such as colors or lights, uncomfortable or painful)
1___2___3___4___5___6___7___8___9
not sensitive.........................extremely
at all....................................sensitive
28. How sensitive are you to hot temperatures?(i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
29. How sensitive are you to cold temperatures?(i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
30. How sensitive are you to odors, such as perfumes, cleaning fluids, etc.? (i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
31. How sensitive are you to many types of textures or touch sensations? (e.g., wool, lotions, skin, etc.)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
32. How sensitive are you to physical pain?
1___2___3___4___5___6___7___8___9
extremely.............................extremely
insensitive............................sensitive
33. Rate your handwriting:
1___2___3___4___5___6___7___8___9
extremely............................unreadable
neat
34. What kind of learner/thinker would you consider yourself?
(a) visual
(b) auditory
© kinesthetic (hands on)
(d) I don't know
35. Do you say things which others have indicated are inappropriate for the situation? (currently)
1___2___3___4___5___6___7___8___9
never.............................always
36. When you were a child, did you say things which others had indicated were inappropriate for the situation?
1___2___3___4___5___6___7___8___9
never.............................always
37. Rate how difficult it is for you to make new friends: (currently)
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
38. Rate how difficult it was for you to make new friends as a child:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
39. Rate how difficult it is to keep the friends you’ve made: (currently)
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
40. Rate how difficult it was when you were a child to keep the friends you’d made:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
41. How honest are you?
1___2___3___4___5___6___7___8___9
I always lie..........................I am always
.........................................honest
42. Do you have a habit of being honest at the wrong times? (i.e., saying things regardless of whether they’re considered appropriate in the social context)
1___2___3___4___5___6___7___8___9
never....................................always
43. Do you have difficulty multitasking in a social situation? (such as listening, looking, planning your next comment, all at the same time)
1___2___3___4___5___6___7___8___9
never....................................always
44. Does socializing wear you out so that you need time to recuperate afterwards?
1___2___3___4___5___6___7___8___9
I find socializing................I always need breaks
invigorating.........................to recuperate
45. Do you have difficulty in knowing how to be emotionally intimate? (not necessarily romantic relationships but also friendships)
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
46. Do you have difficulty identifying another person’s mood or emotions by the expression on his or her face, particularly in real life situations? (i.e., not photographs)
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
47. How much difficulty do you have recognizing people you’ve met before, especially if they are not close friends or family members?
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
48. Were you bullied in school?
1___2___3___4___5___6___7___8___9
never...................................always
49. Did you feel alone and/or ostracized in school?
1___2___3___4___5___6___7___8___9
never...................................always
50. Have you felt especially different from other people throughout your life, as though you “walk to a different drummer”?
1___2___3___4___5___6___7___8___9
never...................................always
51. Have you ever considered yourself a “loner”?
1___2___3___4___5___6___7___8___9
never...................................always
52. When did you develop language as a child?
(a) early (11 months or under)
(b) average (12-23 months)
© late (2 years +)
(d) I don’t know
53. Did you require speech therapy as a child?
(a) no
(b) yes
© I don’t know
54. Do you have a tendency to repeat your own words or someone else’s, either aloud or under your breath?
(a) never
(b) sometimes
© frequently
(d) not now, but when I was younger
55. Do you have a tendency to interpret what another person says literally? (such as someone saying, “I’m burning up!” to indicate they’re hot rather than they’re literally on fire)
1___2___3___4___5___6___7___8___9
never...................................always
56. When you were a child, did you have a tendency to interpret what another person said literally?
1___2___3___4___5___6___7___8___9
never...................................always
57. Do you have difficulty remembering verbal instructions, particularly multi-step instructions?
1___2___3___4___5___6___7___8___9
never...................................always
58. Do you have difficulty keeping track of multiple conversations at once? (e.g., you’re with a group of people and several different conversations are occurring)
1___2___3___4___5___6___7___8___9
never...................................always
59. Do you find when listening to another person, you have difficulty discerning certain words? (such as “ball” versus “fall”)
1___2___3___4___5___6___7___8___9
never...................................always
60. Do you have difficulty translating your thoughts into words?
1___2___3___4___5___6___7___8___9
never....................................always
61. When did you learn to read?
(a) before starting school
(b) once I started school (average)
© late: I was behind my peers
(d) I don't remember
62. How fast do you read?
(a) very fast
(b) average
© very slow
(d) I don't know
1. Rate your comfort level in social situations:
1___2___3___4___5___6___7___8___9
extremely..............................extremely
comfortable.........................uncomfortable
2. In every day situations, how much do you tend to make eye contact with the person you’re talking to?: (This means looking at the eyes, not elsewhere on the face)
1___2___3___4___5___6___7___8___9
a lot......................................none
3. Rate your level of comfort in making eye contact:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
comfortable........................uncomfortable
4. How much do you stutter when you’re anxious?
1___2___3___4___5___6___7___8___9
never....................................always
5. Rate your general, every day stress levels:
1___2___3___4___5___6___7___8___9
no stress...........................extreme stress
6. How often do you avoid things in life because of your anxiety?
1___2___3___4___5___6___7___8___9
never....................................always
7. Do you have a tendency to collect things? (e.g., stamps, cards, coins, etc.)
1___2___3___4___5___6___7___8___9
never....................................always
8. Do you have interests or passions which take up much of your time and thoughts?
1___2___3___4___5___6___7___8___9
never....................................always
9. Do you forego necessities (such as bathroom, food, sleep) when you are actively involved in these interests?
1___2___3___4___5___6___7___8___9
never....................................always
10. When talking with someone, do you tend to talk a lot about one of your special interests?
1___2___3___4___5___6___7___8___9
never....................................always
11. When talking with someone, do you tend to talk more about yourself and focus less on the other person?
1___2___3___4___5___6___7___8___9
never....................................always
12. Do you have difficulty with a change in routine, particularly change imposed upon you by another person, organization, or event?
1___2___3___4___5___6___7___8___9
never....................................always
13. When you have gotten used to doing something, do you prefer to do it the same way each consecutive time?
1___2___3___4___5___6___7___8___9
never....................................always
14. Do you have habits which you perform obsessively, such as washing your hands or checking the door locks, even though you know it isn’t necessary?
1___2___3___4___5___6___7___8___9
never....................................always
15. Would you consider yourself a perfectionist?
1___2___3___4___5___6___7___8___9
no, definitely not................a total perfectionist
16. How organized are you?
1___2___3___4___5___6___7___8___9
extremely..............................extremely
disorganized...........................organized
17. When you are having a conversation with someone, where do you tend to look?
(a) I look at the eyes
(b) I look at the eyes or I look away
© I look at the mouth
(d) I look at the mouth or I look away
(e) I don’t look at the person. I tend to look away
18. When anxious or excited, do you: (multiple selection)
(a) pace
(b) rock
© use repetitive hand gestures (such as hand flapping, finger twisting, hand wringing)
(d) vocal repetitions (such as repeating words over to yourself)
(e) use another form of self-stimulation not listed above
(f) none of the above
19. Rate the variety of your diet:
1___2___3___4___5___6___7___8___9
not limited..........................very limited
at all
20. Would you consider yourself food sensitive?
1___2___3___4___5___6___7___8___9
not sensitive.......................very sensitive
21. How often do you develop “food obsessions” in which you eat a particular type of food for a period of time (sometimes to the point of eating it for every meal)?
1___2___3___4___5___6___7___8___9
never....................................always
22. How is your balance in every day life?
1___2___3___4___5___6___7___8___9
horrible................................excellent
23. How often do you trip, fall, or run into things?
1___2___3___4___5___6___7___8___9
never....................................always
24. How often you find it difficult to find clothes which feel comfortable to you? (not otherwise due to weight, body structure, or finances)
1___2___3___4___5___6___7___8___9
never....................................always
25. How sound sensitive do you consider yourself? (i.e., you find various sounds uncomfortable or painful)
1___2___3___4___5___6___7___8___9
not sensitive.........................extremely
at all...................................sensitive
26. Do you feel overwhelmed and overstimulated in noisy, crowded environments?
1___2___3___4___5___6___7___8___9
never....................................always
27. How light sensitive do you consider yourself? (i.e., you find various visual stimuli, such as colors or lights, uncomfortable or painful)
1___2___3___4___5___6___7___8___9
not sensitive.........................extremely
at all....................................sensitive
28. How sensitive are you to hot temperatures?(i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
29. How sensitive are you to cold temperatures?(i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
30. How sensitive are you to odors, such as perfumes, cleaning fluids, etc.? (i.e., level of discomfort)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
31. How sensitive are you to many types of textures or touch sensations? (e.g., wool, lotions, skin, etc.)
1___2___3___4___5___6___7___8___9
not at all..............................extremely
.........................................sensitive
32. How sensitive are you to physical pain?
1___2___3___4___5___6___7___8___9
extremely.............................extremely
insensitive............................sensitive
33. Rate your handwriting:
1___2___3___4___5___6___7___8___9
extremely............................unreadable
neat
34. What kind of learner/thinker would you consider yourself?
(a) visual
(b) auditory
© kinesthetic (hands on)
(d) I don't know
35. Do you say things which others have indicated are inappropriate for the situation? (currently)
1___2___3___4___5___6___7___8___9
never.............................always
36. When you were a child, did you say things which others had indicated were inappropriate for the situation?
1___2___3___4___5___6___7___8___9
never.............................always
37. Rate how difficult it is for you to make new friends: (currently)
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
38. Rate how difficult it was for you to make new friends as a child:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
39. Rate how difficult it is to keep the friends you’ve made: (currently)
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
40. Rate how difficult it was when you were a child to keep the friends you’d made:
1___2___3___4___5___6___7___8___9
extremely.............................extremely
easy....................................difficult
41. How honest are you?
1___2___3___4___5___6___7___8___9
I always lie..........................I am always
.........................................honest
42. Do you have a habit of being honest at the wrong times? (i.e., saying things regardless of whether they’re considered appropriate in the social context)
1___2___3___4___5___6___7___8___9
never....................................always
43. Do you have difficulty multitasking in a social situation? (such as listening, looking, planning your next comment, all at the same time)
1___2___3___4___5___6___7___8___9
never....................................always
44. Does socializing wear you out so that you need time to recuperate afterwards?
1___2___3___4___5___6___7___8___9
I find socializing................I always need breaks
invigorating.........................to recuperate
45. Do you have difficulty in knowing how to be emotionally intimate? (not necessarily romantic relationships but also friendships)
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
46. Do you have difficulty identifying another person’s mood or emotions by the expression on his or her face, particularly in real life situations? (i.e., not photographs)
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
47. How much difficulty do you have recognizing people you’ve met before, especially if they are not close friends or family members?
1___2___3___4___5___6___7___8___9
no difficulty...........................extreme
.........................................difficulty
48. Were you bullied in school?
1___2___3___4___5___6___7___8___9
never...................................always
49. Did you feel alone and/or ostracized in school?
1___2___3___4___5___6___7___8___9
never...................................always
50. Have you felt especially different from other people throughout your life, as though you “walk to a different drummer”?
1___2___3___4___5___6___7___8___9
never...................................always
51. Have you ever considered yourself a “loner”?
1___2___3___4___5___6___7___8___9
never...................................always
52. When did you develop language as a child?
(a) early (11 months or under)
(b) average (12-23 months)
© late (2 years +)
(d) I don’t know
53. Did you require speech therapy as a child?
(a) no
(b) yes
© I don’t know
54. Do you have a tendency to repeat your own words or someone else’s, either aloud or under your breath?
(a) never
(b) sometimes
© frequently
(d) not now, but when I was younger
55. Do you have a tendency to interpret what another person says literally? (such as someone saying, “I’m burning up!” to indicate they’re hot rather than they’re literally on fire)
1___2___3___4___5___6___7___8___9
never...................................always
56. When you were a child, did you have a tendency to interpret what another person said literally?
1___2___3___4___5___6___7___8___9
never...................................always
57. Do you have difficulty remembering verbal instructions, particularly multi-step instructions?
1___2___3___4___5___6___7___8___9
never...................................always
58. Do you have difficulty keeping track of multiple conversations at once? (e.g., you’re with a group of people and several different conversations are occurring)
1___2___3___4___5___6___7___8___9
never...................................always
59. Do you find when listening to another person, you have difficulty discerning certain words? (such as “ball” versus “fall”)
1___2___3___4___5___6___7___8___9
never...................................always
60. Do you have difficulty translating your thoughts into words?
1___2___3___4___5___6___7___8___9
never....................................always
61. When did you learn to read?
(a) before starting school
(b) once I started school (average)
© late: I was behind my peers
(d) I don't remember
62. How fast do you read?
(a) very fast
(b) average
© very slow
(d) I don't know
Thanks!
