Asperger’s Syndrome Checklist

Patient Name:  	

Date:  	

Instructions: Pick out the one answer that best describes the way you have been feeling during the past two weeks, including today. Circle the number of the correct answer. Please do not choose more than one number for each statement.

Respond to each statement as best you can using the answer key below:
0 = Not a problem at all
1 = A mild problem, that is bothersome but doesn’t interfere with daily activities
2 = A moderate problem, that does interfere with daily activities
3 = A severe problem, which makes it very hard to have a normal day at all

ARE ANY OF THESE SYMPTOMS PRESENT?	Not a
Problem	
Mild	
Moderate	
Severe	
1.   Preoccupied by favorite interest/topic	0	1	2	3	
2.   Difficulty using/interpreting nonverbal cues	0	1	2	3	
3.   Inability to develop peer relationships	0	1	2	3	
4.   Difficulty transitioning/likes routine	0	1	2	3	
5.   Anxious	0	1	2	3	
6.   Depressed	0	1	2	3	
7.   Disorganized	0	1	2	3	
8.   Overly sensitive to sounds/tastes/textures	0	1	2	3	
9.   Overly sensitive to criticism	0	1	2	3	
10. Stereotypical movements/behaviors	0	1	2	3	
11. Clumsy/Uncoordinated	0	1	2	3	
12. Aware he/she is different from others	0	1	2	3	
13. Limits or avoids eye contact	0	1	2	3	
14. Prefers to spend time with adults rather than peers	0	1	2	3	
15. Asks inappropriate questions or makes inappropriate
statements	
0	
1	
2	
3	
16. Speaks in an academic or very adult manner	0	1	2	3	
17. Facial expressions are minimal or inappropriate	0	1	2	3	
18. Difficulty with activities that require fine motor skills, such as
writing or buttoning	
0	
1	
2	
3	
19. Little respect for personal space or physical boundaries	0	1	2	3	
20. Difficulty understanding sarcasm, metaphors, subtle jokes	0	1	2	3	

Mean Item Score:		
Total Score: