Child’s Name: .................................. Age: .........................             Sex:     Male / Female

Birth Order: ..................................... Twin or Single Birth: ..................................

Parent/Guardian: .....................................................................................................

Parent(s) occupation: ............................................................................................

Age parent(s) left full-time education: ....................................................................

Address: .................................................................................................................

Tel.No: .................................. School: ........................................................

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1. Does s/he join in playing games with other children easily? Yes                  No

2. Does s/he come up to you spontaneously for a chat? Yes                  No

3. Was s/he speaking by 2 years old? Yes                  No

4. Does s/he enjoy sports? Yes                  No

5. Is it important to him/her to fit in with the peer group? Yes                  No

6. Does s/he appear to notice unusual details that  others miss?                                                                                    Yes                  No

7. Does s/he tend to take things literally? Yes                  No

8. When s/he was 3 years old‚ did s/he spend a lot of time  pretending (e.g.‚ play-acting being a superhero‚ or

9. Does s/he like to do things over and over again‚ in the same way all the time?                                                          Yes                  No

10. Does s/he find it easy to interact with other children?                                                                           Yes                  No

11. Can s/he keep a two-way conversation going? Yes                  No

12. Can s/he read appropriately for his/her age? Yes                  No

13. Does s/he mostly have the same interests as his/her peers?                                                                     Yes                  No

14. Does s/he have an interest which takes up so much  time that s/he does little else?                                             Yes                  No

15. Does s/he have friends‚ rather than just acquaintances? Yes                  No

16. Does s/he often bring you things s/he is interested in to show you?                                                                Yes                  No

17. Does s/he enjoy joking around? Yes                  No

18. Does s/he have difficulty understanding the rules for polite behaviour?                                                         Yes                  No

19. Does s/he appear to have an unusual memory for details?                                                                              Yes                  No

20. Is his/her voice unusual (e.g.‚ overly adult‚ flat‚ or  very monotonous)?                                                                       Yes                  No

21. Are people important to him/her? Yes                  No

22. Can s/he dress him/herself? Yes                  No

23. Is s/he good at turn-taking in conversation? Yes                  No

24. Does s/he play imaginatively with other children‚ and engage in role-play?                                                Yes                  No

25. Does s/he often do or say things that are tactless or socially inappropriate?                                                  Yes                  No

26. Can s/he count to 50 without leaving out any numbers?                                                                          Yes                  No

27. Does s/he make normal eye-contact? Yes                  No

28. Does s/he have any unusual and repetitive movements?                                                                      Yes                  No

29. Is his/her social behaviour very one-sided and always on his/her own terms?                                           Yes                  No

30. Does s/he sometimes say “you” or “s/he” when s/he means “I”?                                                                 Yes                  No

31. Does s/he prefer imaginative activities such as play-acting or story-telling‚ rather than numbers

32. Does s/he sometimes lose the listener because of not explaining what s/he is talking about?                         Yes                  No

33. Can s/he ride a bicycle (even if with stabilisers)? Yes                  No

34. Does s/he try to impose routines on him/herself‚ or on others‚ in such a way that it causes problems?                     Yes                  No

35. Does s/he care how s/he is perceived by the rest of  the group?                                                                         Yes                  No

36. Does s/he often turn conversations to his/her favourite subject rather than following what the other

37. Does s/he have odd or unusual phrases? Yes                  No

38. Have teachers/health visitors ever expressed any concerns about his/her development?                               Yes                  No

If Yes‚ please specify..................................................................................................

39. Has s/he ever been diagnosed with any of the following?:

Language delay Yes                  No

Hyperactivity/Attention Deficit Disorder (ADHD) Yes                  No

Hearing or visual difficulties Yes                  No

Autism Spectrum Condition‚ incl. Asperger’s Syndrome Yes                  No

A physical disability Yes                  No

Other (please specify) Yes                  No

http://www.autismresearchcentre.com/arc_tests