Q-CHAT QuestionnaireQuantitative Checklist for Autism in Toddlers (Q-CHAT)The Quantitative Checklist for Autism in Toddlers (Q-CHAT) is a questionnaire which aims to identify toddlers aged 18 to 30 months old who may have autism. Please provide as much information as possible. Mandatory fields are marked *Child's First NameChild's Last Name First Born Second Born Third Born Last Born Single Birth TwinChild's AgePrefered Name / NicknamePatient Gender- Select -MaleFemaleOthersParent/Guardian First NameParent/Guardian Last NameOccupationCurrent Address:CityProvincePostal CodePhone NumberQ-CHAT QuestionnairePlease read the following questions carefully, and select the appropriate answer. All responses are confidential.1. Does your child look at you when you call his/her name?1. Does your child look at you when you call his/her name? Always Usually Sometimes Rarely Never2. How easy is it for you to get eye contact with your child?2. How easy is it for you to get eye contact with your child? Very easy Quite easy Quite difficult Very difficult Impossible3. When your child is playing alone, does s/he line objects up?3. When your child is playing alone, does s/he line objects up? Always Usually Sometimes Rarely Never4. Can other people easily understand your child’s speech?4. Can other people easily understand your child’s speech? Always Usually Sometimes Rarely Never My child does not speak5. Does your child point to indicate that s/he wants something (e.g. a toy that is out of reach)?5. Does your child point to indicate that s/he wants something (e.g. a toy that is out of reach)? Many times a day A few times a day A few times a week Less than once a week Never6. Does your child point to share interest with you (e.g. pointing at an interesting sight)?6. Does your child point to share interest with you (e.g. pointing at an interesting sight)? Many times a day A few times a day A few times a week Less than once a week Never7. How long can your child’s interest be maintained by a spinning object (e.g. washing machine, electric fan, toy car wheels)?7. How long can your child’s interest be maintained by a spinning object (e.g. washing machine, electric fan, toy car wheels)? Several hours Half an hour Ten minutes A couple of minutes Less than a minute8. How many words can your child say?8. How many words can your child say? None, s/he has not started speaking yet Less than 10 words 10–50 words 51–100 words Over 100 words9. Does your child pretend (e.g. care for dolls, talk on a toy phone)?9. Does your child pretend (e.g. care for dolls, talk on a toy phone)? Many times a day A few times a day A few times a week Less than once a week Never10. Does your child follow where you’re looking?10. Does your child follow where you’re looking? Many times a day A few times a day A few times a week Less than once a week Never11. How often does your child sniff or lick unusual objects?11. How often does your child sniff or lick unusual objects? Many times a day A few times a day A few times a week Less than once a week Never12. Does your child place your hand on an object when s/he wants you to use it (e.g. on a door handle when s/he wants you to open the door, on a toy when s/he wants you to activate it)?12. Does your child place your hand on an object when s/he wants you to use it (e.g. on a door handle when s/he wants you to open the door, on a toy when s/he wants you to activate it)? Many times a day A few times a day A few times a week Less than once a week Never13. Does your child walk on tiptoe?13. Does your child walk on tiptoe? Always Usually Sometimes Rarely Never14. How easy is it for your child to adapt when his/her routine changes or when things are out of their usual place?14. How easy is it for your child to adapt when his/her routine changes or when things are out of their usual place? Very easy Quite easy Quite difficult Very difficult Impossible15. If you or someone else in the family is visibly upset, does your child show signs of wanting to comfort them (e.g. stroking their hair, hugging them)?15. If you or someone else in the family is visibly upset, does your child show signs of wanting to comfort them (e.g. stroking their hair, hugging them)? Always Usually Sometimes Rarely Never16. Does your child do the same thing over and over again (e.g. running the tap, turning the light switch on and off, opening and closing doors)?16. Does your child do the same thing over and over again (e.g. running the tap, turning the light switch on and off, opening and closing doors)? Many times a day A few times a day A few times a week Less than once a week Never17. Can other people easily understand your child’s speech?17. Can other people easily understand your child’s speech? Very typical Quite typical Slightly unusual Very unusual My child does not speak18. Does your child echo things s/he hears (e.g. things that you say, lines from songs or movies, sounds)?18. Does your child echo things s/he hears (e.g. things that you say, lines from songs or movies, sounds)? Many times a day A few times a day A few times a week Less than once a week Never19. Does your child use simple gestures (e.g. wave goodbye)?19. Does your child use simple gestures (e.g. wave goodbye)? Many times a day A few times a day A few times a week Less than once a week Never20. Does your child make unusual finger movements near his/her eyes?20. Does your child make unusual finger movements near his/her eyes? Many times a day A few times a day A few times a week Less than once a week Never21. Does your child spontaneously look at your face to check your reaction when faced with something unfamiliar?21. Does your child spontaneously look at your face to check your reaction when faced with something unfamiliar? Always Usually Sometimes Rarely Never22. How long can your child’s interest be maintained by just one or two objects?22. How long can your child’s interest be maintained by just one or two objects? Most of the day Several hours Half an hour Ten minutes A couple of minutes23. Does your child twiddle objects repetitively (e.g. pieces of string)?23. Does your child twiddle objects repetitively (e.g. pieces of string)? Many times a day A few times a day A few times a week Less than once a week Never24. Does your child seem oversensitive to noise?24. Does your child seem oversensitive to noise? Always Usually Sometimes Rarely Never25. Does your child stare at nothing with no apparent purpose?25. Does your child stare at nothing with no apparent purpose? Many times a day A few times a day A few times a week Less than once a week NeverAdditional InformationPlease include any details that may not have been questioned on this form.Submit Form
