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Autism Spectrum Screening DSM-5 Checklist
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A: Deficits in Communication and Social Interaction
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1) Deficits in Social Communication and Social Interaction
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Comments:
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Criteria for Category A, Section 1
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2) Deficits in Nonverbal Communicative Behaviors
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Comments:
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Criteria for Category A, Section 2
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3) Deficits in developing, maintaining, and understanding relationships
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Comments:
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Criteria for Category A, Section 3
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Meets Full Criteria for Deficits in Social Communication and Social Interaction
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Current Severity of Category A
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B: Restricted, Repetitive Patterns of Behavior, Interests or Activities
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1) Restricted, Repetitive Patterns of Behaviors, Interest, or Activities
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Comments:
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Criteria for Category B Section 1
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2) Insistence on Sameness, Routines, or Rituals
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Comments:
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Criteria for Category B, Section 2
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3) Highly Fixated Intense Interests
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Comments:
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Criteria for Category B, Section 3
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4) Reactivity to Sensory Input
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Comments:
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Criteria for Category B, Section 4
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Current Severity of Category B
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C: Symptoms must be presents early
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Symptoms present early
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D: Symptoms Cause Clinical Impairment
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Symptoms Cause Impairment
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E) Not Better Explained by Disability or Development Delay
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Not Explained by Intellectual Disability or Delay
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Autism Criteria Met
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Autism Spectrum Disorder Criteria Met
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Intellectual Impairment
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Intellectual Impairment
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Language Impairment
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Language Impairment
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Associated With
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Associated with:
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Other Common Comorbidites Associated with Autism Spectrum Disorder
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Atypical Developmental Pattern
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Comments:
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Mood Disturbance
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Comments:
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Problems with Safety
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Comments
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Diet
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Toilet Training
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Other Relevant Autism Diagnostic Comments
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