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Required format:

INnTkmzpe7IoLUboMEB736hV

Quantitative Checklist for Autism in Toddlers (Q-CHAT) - Over Age 2

Please fill out the following survey assessing your child's risk for autism. After you complete all the questions, your child's autism risk score will be calculated for you. We will also email you the results for your records.

The Q-CHAT assessment is typically used for children between the ages of 18-36 months. Outside of this range, it will not be reliable.

Do you agree to participate in our autism research study as described in the Chatter Baby Consent Form, Privacy Policy, and UCLA Terms of Use ?

* must provide value

Yes

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* must provide value

Child's Gender

* must provide value

Male

Female

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Date of Birth

* must provide value

Y-M-D

Child's age in years:

* must provide value

View equation

Has your child lost any skills (movement, language, etc...) that they once had?

Yes

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Please describe the lost skills, and when this occurred.

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Today, does your child have a current diagnosis of any of the following:

Deaf or moderate-to-severe hearing impaired

Autism Spectrum Disorder

Pervasive Developmental Disorder, Not Otherwise Specified

Cognitive delay

Speech or language delay

Motor delay

Developmental delay

Social-emotional delay

Adaptive-behavior delay

Other (seizure, cardiac disorder, etc...)

Other diagnosis for child (please specify):

In which language domain did your child receive a diagnosis?

Speech

Expressive Language

Receptive Language

Has your child's sibling been diagnosed with any of the following at any point in their childhood:

Deaf or moderate-to-severe hearing impaired

Autism Spectrum Disorder

Pervasive Developmental Disorder, Not Otherwise Specified

Cognitive delay

Speech or language delay

Motor delay

Developmental delay

Social-emotional delay

Adaptive-behavior delay

Attention Deficit Hyperactivity Disorder (ADHD)

Other

Other sibling diagnosis (please specify):

Older brother

Older sister

Younger brother

Younger sister

Older half-brother

Older half-sister

Younger half-brother

Younger half-sister

Twin brother

Twin sister

Deaf or moderately-to-severely hearing impaired

Autism Spectrum Disorder

Pervasive Developmental Disorder, Not Otherwise Specified

Cognitive Delay

Speech or Language Delay

Motor Delay

Developmental Delay

Social-emotional Delay

Adaptive-behavior Delay

Attention Deficit Hyperactivity Disorder (ADHD)

Other

Is your child receiving Early Intervention or any therapy services such as speech, occupational, etc...?

Yes

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Please describe which services your child is receiving, and when.

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Does your child have any unusual behaviors?

Yes

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Please describe the unusual behaviors.

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Does your child look at you when you call his/her name?

* must provide value

How easy is it for you to get eye contact with your child?

* must provide value

When your child is playing alone, does s/he line objects up?

* must provide value

Can other people easily understand your child's speech?

* must provide value

Does your child point to indicate that s/he wants something (e.g. a toy that is out of reach)

* must provide value

Does your child point to share interest with you (e.g. pointing at an interesting sight)?

* must provide value

How long can your child's interest be maintained by a spinning object (e.g. washing machine, electric fan, toy car wheels)?

* must provide value

How many words can your child say?

* must provide value

Does your child pretend (e.g. care for dolls, talk on a toy phone)?

* must provide value

Does your child follow where you're looking?

* must provide value

How often does your child sniff or lick unusual objects?

* must provide value

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)?

* must provide value

Does your child walk on tiptoe?

* must provide value

How easy is it for your child to adapt when his/her routine changes or when things are out of their usual place?

* must provide value

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)?

* must provide value

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)?

* must provide value

Would you describe your child's first words as:

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Does your child echo things s/he hears (e.g. things that you say, lines from songs or movies, sounds)?

* must provide value

Does your child use simple gestures (e.g. wave goodbye)?

* must provide value

Does your child make unusual finger movements near his/her eyes?

* must provide value

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

* must provide value

How long can your child's interest be maintained by just one or two objects?

* must provide value

Does your child twiddle objects repetitively (e.g. pieces of string)?

* must provide value

Does your child seem oversensitive to noise?

* must provide value

Does your child stare at nothing with no apparent purpose?

* must provide value

Do you have any other concerns about your child's development?

Yes

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Please describe your concerns here.

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Q-CHAT (Quantitative CHecklist for Autism in Toddlers) Score:

View equation

Your results will be provided on the next page, and will also be emailed to you. Please click Submit to complete the survey.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.