Please read the following statements carefully. For each statement that you think suits your child's / student's condition, select one of the "Mild", "Moderate" or "Severe" options.
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1/11
1.
Does not know his-her own name or surname
LightMediumSevere
2.
Insensitive to pain or temperature
3.
Does not know the names of his-her own family members
4.
Overly attached to his-her mother
5.
Experiences problems due to his-her parents' divorce
6.
As his-her parent I think he-she is affected negatively by disagreements
7.
Has difficulties in making and maintaining friendships
8.
Overly hyper
9.
Overly anxious
10.
Cannot put on his-her shoes without help
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2/11
11.
Cannot perform simple additions
12.
Overly interested in certain specific areas or mostly just talks about those said interests
13.
Gives up easily when faced with an obstacle
14.
Cannot tell the function of objects (E.g., what do we do with a toothbrush?)
15.
Does meaningless repetitive behaviours such as clapping, stimming
16.
Speaks nasally
17.
Does not know concepts such as big or small, long or short, etc.
18.
Has no interest towards studies
19.
Shy and introvert
20.
Does not react to the sounds around them (human voice, car honks, etc.)
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3/11
21.
Has trouble navigating an area even when they know it very well
22.
Often speaks too much
23.
Often interrupts others or cuts in on them
24.
Often cannot play or join leisure activities quietly
25.
Often finishes other people’s sentences
26.
Often wiggles, stomps his-her hands or feet or fidgets where he-she sits
27.
Often cannot wait his-her turn in a conversation
28.
Often stands up in situations where he-she is expected to sit
29.
Often acts first and thinks later instead of the other way around
30.
Often answers questions before he-she hears them in full
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4/11
31.
While in unsuitable environments, often runs around or climbs things
32.
Often yells while speaking
33.
Often speaks in a whispering manner
34.
Has attention problems
35.
Cannot answer questions about a short story he-she just listened to
36.
Has trouble unbuttoning
37.
Has trouble buttoning up
38.
Has trouble maintaining balance while walking
39.
Cannot wash his-her hands without help
40.
Wets the bed during the night
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5/11
41.
Cannot sleep alone
42.
Avoids eye contact
43.
Wets themselves during the day
44.
Wants to take the same route or eat the same thing everyday
45.
Objects to everything
46.
Has communication issues
47.
Cannot draw a human figure
48.
Indifferent towards people
49.
Does not react to his-her own name
50.
Overly hasty while working, cannot wait for his-her turn
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6/11
51.
Has appetite and eating problems such as overeating or being an overly picky eater
52.
Does not know his-her own sex
53.
Has a recurring speech pattern that is unique to him-her
54.
Tries to communicate with signs (like gesturing and pointing) while expressing himself-herself
55.
Has difficulty understanding and following instructions (E.g., close the door, throw away the paper, sit down, etc.)
56.
Does not react to commands (E.g., go, come, sit, etc.)
57.
His-her speech rate is faster than average and his-her speech less understandable than average
58.
His-her speech is not understandable, strangers cannot understand what he-she is saying
59.
When speaking, substitutes some letters for others or altogether passes them (E.g., pine, pne)
60.
Stutters while speaking
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7/11
61.
Has trouble playing games with rules, such as hide and seek
62.
Shows huge reactions to small changes
63.
Has trouble cutting out things (e.g., pictures) with scissors
64.
Has difficulty in walking up and down the stairs
65.
Cannot sort things according to their categories (animals, fruits, reds, etc.)
66.
Prefers to never speak aloud at places such as school
67.
Has trouble focusing while playing
68.
Has trouble playing with toys in a way that suits their purpose
69.
Quickly forgets what he-she learns
70.
Has low self-esteem
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10/11
71.
Sucks his-her thumb
72.
Cannot recognize colours
73.
Cannot copy simple shapes shown in pictures
74.
Pulls out his-her hair and eyebrows
75.
Confuses left and right
76.
Shows aggressive behaviours
77.
Cannot count rhythmically
78.
Has trouble chewing and-or swallowing solid foods
79.
Has trouble detecting which direction a sound comes from
80.
Frequently cries without a reason
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8/11
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9/11
81.
Frequently has anger tantrums
82.
Stumbles frequently, cannot see small obstacles while walking and stumbles over them
83.
Cannot easily understand what is being said nor follow through with it
84.
Has an extremely limited vocabulary
85.
Has obsessions
86.
Cannot imitate their parents' behaviours, speech or movements
87.
Cannot protect himself-herself from danger (fire, broken glass, etc.)
88.
Has problems with his-her pronunciation
89.
Is overly interested in watching ads on TV or watching spinning things like the washing machine
90.
Bites his-her nails
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91.
Has tics
92.
Cannot kick the ball with his-her feet
93.
Cannot go to the toilet without assistance
94.
Has inappropriate and-or unusual emotional reactions
95.
Has trouble with his-her sleep (e.g., sleepwalking, frequent nightmares, etc.)
96.
Cannot read facial expressions that indicate emotions such as sadness, anger, happiness, fear, shock, etc.
97.
Is overly friendly to strangers
98.
Prefers to play alone
99.
Has trouble getting dressed by himself-herself
100.
Cannot recount experiences he-she had or a movie plot in a chronological sequence
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11/11
101.
Has a lot of fears for his-her age
102.
Does not know his-her own age
103.
Cannot eat without help
104.
Has trouble adapting to new situations
105.
Has trouble jumping on the same spot
106.
Avoids activities that might be challenging
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Your Name and Surname*
Your E-mail Address*
Your Phone Number*
Your Child's Name*
Your Child's Date of Birth*
* Please fill in the marked areas carefully to ensure the Dilgem experts can reach you promptly.
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Bahçelievler Mh. Eber Sk. No:2/5 Pendik - İstanbulPendik/İstanbul
+905331656094
info@dilgem.com.tr