Q-CHAT Questionnaire

Quantitative 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 Name

Child's Last Name

Child's Age

Prefered Name / Nickname

Patient Gender

Parent/Guardian First Name

Parent/Guardian Last Name

Occupation

Current Address:

City

Province

Postal Code

Phone Number

Please read the following questions carefully, and select the appropriate answer. All responses are confidential.

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

Never

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

Never

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 minute

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

Never

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

Never

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

Impossible

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

Never

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

Never

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

Never

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

Never

21. Does your child spontaneously look at your face to check your reaction when faced with something unfamiliar?

Always

Usually

Sometimes

Rarely

Never

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 minutes

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

Never

Additional Information

Please include any details that may not have been questioned on this form.

Quantitative Checklist for Autism in Toddlers (Q-CHAT)

Q-CHAT Questionnaire

Additional Information

Recent Posts

Childhood Vaccines in Peel Region: A Parent’s Quick Guide

Insect Repellents Safely For Kids

Contact Us