Section A - Ask Parent:

Yes or No?

____ 1) Does your child enjoy being swung, bounced on your knee, etc?

____ 2) Does your child take an interest in other children?

____ 3) Does your child like climbing on things, such as up stairs?

____ 4) Does your child enjoy playing peek-a-boo/hide-and-seek?

____ *5) Does your child ever pretend, for example, to make a cup of tea using a toy cup and teapot, or pretend other things?

____ 6) Does your child ever use his/her index finger to point, to ask for something?

____ *7) Does your child ever use his/her index finger to point, to indicate interest in something?

____ 8) Can your child play properly with small toys (e.g. cars or bricks) without just mouthing, fiddling, or dropping them?

____ 9) Does your child ever bring objects over to you, to show you something?

Section B - GP's observation

Yes or No?

____ i) During the appointment, has the child made eye contact with you?

____ *ii) Get child's attention, then point across the room at an interesting object and say "Oh look! There's a (name a toy)!" Watch child's face. Does the child look across to see what you are pointing at?

NOTE - to record yes on this item, ensure the child has not simply looked at your hand, but has actually looked at the object you are pointing at.

____ *iii) Get the child's attention, then give child a miniature toy cup and teapot and say "Can you make a cup of tea?" Does the child pretend to pour out the tea, drink it etc?

NOTE - if you can elicit an example of pretending in some other game, score a yes on this item

____ *iv) Say to the child "Where's the light?" or "Show me the light". Does the child point with his/her index finger at the light?

NOTE - Repeat this with "Where's the teddy?" or some other unreachable object, if child does not understand the word "light". To record yes on this item, the child must have looked up at your face around the time of pointing.

____ v) Can the child build a tower of bricks? (If so, how many?) (Number of bricks...)

* Indicates critical question most indicative of autistic characteristics