WCAP

World Community Autism Program

Providing information and services for people all over the world

impacted by Autism and related conditions.


World Community Autism Program

E-mail:  sojmed@gmail.com

Word version of worksheet



Speech and Language
Auditory Integration Therapy
Physiotherapy referral

Art therapy
Counseling


In person:
'ASD' Diagnostic Assessment and Recommendations (Written Report)
Behavioral consultation

Via internet, mail, phone or in person:
Nutrition consultation


WORKSHEET
WCAP © copyright 2002 updated 2006
World Community Autism Program Publishing Division


Worksheet for:

Birth date:

Parent or Guardian

Address:          

 


Phone:                                                Mobile:

E-mail:
                  
Emergency Contact:

Known Allergies:

 

Physician:

Specialist service providers (optional):


Medical History (include surgeries, jaundice at birth, medications, otitis media, frequent colds):
                       

 

 

 

 



                        
Family medical history: (Arthritis, Heart disease, Cancer, MS, Other)

Mother:            


Motherís mother:

Motherís father:

Father:

Fatherís mother:

Fatherís father:

Siblings (age/sex.known medical or mental health conditions?):

   

                        
Stool (Describe): Colour, solid or loose, frequency:

                        

Foods accepted: (list)
PROTEIN
               Meats:_________________________________________

               Eggs:  _________________________________________

               Beans: _________________________________________

               Dairy: _________________________________________

               Nuts:  _________________________________________

GRAINS AND STARCH (potato, brown rice, white rice, yellow corn, white corn, sorghum, oats, rye, barley, millet, other):   
       
                          _________________________________________

                         _________________________________________

FRUITS and JUICE (list)

                         _________________________________________

                         _________________________________________

                         _________________________________________

VEGETABLES (list) Cooked:
                         _________________________________________

                         _________________________________________

                         _________________________________________

                         _________________________________________

                         _________________________________________

VEGETABLES (list) Raw i.e. salad:
                         _________________________________________

                         _________________________________________

                         _________________________________________

SUGAR (table sugar, honey, syrups, soda, candy) describe:
                         _________________________________________

                         _________________________________________

                         _________________________________________

                         _________________________________________
SPICES:
                         _________________________________________

                         _________________________________________

                         _________________________________________

FATS/OILS: (circle) Olive, Soybean, Walnut, Sesame, Canola other (list):



Cooking pans (cast iron, aluminium, glass, stainless steel):

                    

Water source (usual)

Budget can accommodate supplement, additional testing?  (delete one) Yes    No
                       



WCAP Checklist for Autism Spectrum Disorder    
WCAP Publishing © copyright 2002


1. Facial expression
a.   eyes
____ doesn’t raise eyebrows when surprised
____ dazed or blank expression
____ eye movement is uncoordinated, eyes appear to look in different directions
____ squints
____ does not make eye contact
____ visual fixations on light, colour, moving objects, fingers
____ does not make tears
____ does not look in direction of sound stimulus
____ does not blink
____ intense eye gaze
____ threatening eye gaze

b.  mouth
____ does not or cannot smile
____ limited ability to control facial muscles
____ upper lip (filtrum area) appears numb
____ dreamy smile

c. general
____ face lacks expression, appears vague
____ worried or concerned look
____ threatened or frightened look
____ threatening or agitated expression

2. Social Interaction
_____ Chooses to be alone
_____ Self-entertaining
_____ Social interaction initiates slowly after trust has been established
_____ Prefers to watch rather than participate
_____ Attempts new activities in private
_____ Secretive – hides things
_____ Unconcerned with appearance
_____ Obsessive about appearance (tidy)
_____ Lacks reciprocal interaction
_____ Does not point or make needs known with normal body language

3. Speech, language and communication

_____ Temper tantrum when routine is changed
_____ Expresses desires through temper tantrum
_____ No verbal language
_____ Echolalia
_____ Single-words and short sentences
_____ Confused or incoherent babbling
_____ improper use of pronouns (I, you, he, she)
_____ does not reciprocate conversationally
_____ Extensive memory for words
_____ Makes lists
_____ fantasy language
_____ talks to invisible companion(s)
_____ fixates on specific videos, TV programs:

        which ones? _______________________________________________________

_____ repetitive use of certain words and phrases:
       
        which ones?  _____________________________________________________
_____ no regard for personal space
_____ demands to be carried
_____ refuses to move
_____ poor pragmatic language skills
_____ manipulative
_____ demanding

4. Movement and body language
_____ ataxic gait (walks like drunk)
_____ mechanical movement, walking
_____ walks on balls of feet or tip-toes
_____ walks with hands in the air and elbows extended
_____ walks like jello
_____ never stops moving
_____ very fast sudden movement
_____ jumps
_____ spinning in circles
_____ pacing
_____ hand flapping
_____ moves fingers in front of eyes
_____ lethargic
_____ rocks from side to side
_____ rocks from forward to back
_____ sways head
_____ flicks fingers
____ _repetitive touching of objects, people or self
_____ hits self
_____ beats repetitively on certain body parts e.g. Ears, face, head, chest

which one?_______________________________

_____ teeth grinding or clenching
_____ moves towards light, coloured objects, food
_____ moves away from sound, movement, people
_____ manipulates objects with great skill

5. Obsessions
a.    Water
b.    Specific objects
c.    Routine
d.    Clothes
e.    Food
f.    Light
g.    Colour
h.    Words
i.    Tidiness
j.    Cleanliness
k.    Destruction
l.    Chaos
m.    Mud
n.    Dirt
o.    Faecal matter
p.    Names
q.    Dates
r.    Spelling
s.    Numbers
t.    Stacking
u.    Puzzles
v.    Time
w.   Writing Utensils
x.    Entertainment equipment – CDs, TVs, VCRs, Nintendo
y.    Music
z.    Books, magazines
aa.    Motor Transport – cars, trains, planes
bb.    Schedules – bus timetables, racing schedules, etc.
cc.    Calendars and maps

5b. Unusual attachment to objects
____  Has a collection of comfort objects
____  Must carry a comfort object
____  Lines them up
____  Spins them
____  Stacks them
____  Hides them
____  Counts them
____  Collects them
____  Uses them as a tool for communication

6. Food
_____ Difficulty in breast-feeding
_____ Vomiting in infancy
_____ difficulty with formula
_____ difficulty with swallowing
_____ does not chew
_____ sensitive teeth
_____ eats with hands
_____ rejects solid food
_____ smells food before eating
_____ touches food
_____ spits out food
_____ gags on food
_____ vomiting at meal time
_____ very limited food choices

only eats: _______________________________________________

_______________________________________________________

_______________________________________________________

_____eats non-food items

such as: ____________________________________

_____ tense as mealtime approaches
_____ won't come to table
_____ tantrums during mealtimes
_____ seizures during mealtimes
_____ seizures just after mealtimes
_____ throws food
_____ steals food
_____ hordes food
_____ escapes and is found in kitchen
_____ eats certain foods ravenously and obsessively

    such as:________________________________________

____________________________________________________

_____refuses to eat
_____refuses certain foods

    such as:________________________________________

____________________________________________________

____________________________________________________

7. Light and Sound
_____ Fear of mechanical noise
_____ Fear of sharp sounds e.g. dog barking, car alarm
_____ Fear of simple sounds e.g. dripping water
_____ Covers ears regularly
_____ Demands music
_____ Sings
_____ Hums
_____ Clicks tongue
_____ Makes tapping sounds
_____ Likes to control sound and noise
_____ Throws things to make a noise
_____ Stares
_____ Stands at window
_____ Squints in sunlight
_____ Obsessed with prisms, rainbows and color patterns
_____ Watches coloured lights
_____ Watches dust particles in the light (shakes things to make dust)
_____ Pushes eyeball to make colour patterns
_____ Pulls corner of the eye

8. Behavior
_____ Demands sameness of routine
_____ Does not share
_____ Does not participate
_____ Does not initiate
_____ Does not go first
_____ invades personal space such as touching or climbing on people
_____ lack of stranger anxiety
_____ lack of separation anxiety
_____ unconcerned with social appearance
_____ playing with saliva
_____ picking at skin
_____ hyperventilation
_____s elf-stimulation (masturbation)

9. Somatosensory response/ Atypical Developmental Pattern

_____ Love of movement, frolic play, tickling, climbing, rocking, swinging
_____ Unresponsive at times to verbal input (e.g., not reacting when name called, hearing may be questioned even though normal)
_____ Hypersensitivity to some sounds (e.g., distress or covering ears in response to loud noise, sounds made by appliances or motors, or certain            songs, commercials, or voices)
_____ Distress with commotion, crowds
_____ Fascination with specific visual stimuli such as spinning or rhythmic movements, details, fingers, lights, shiny surfaces, linear patterns (e.g., credits on TV, fans)
_____ Abnormal sensory inspection (e.g., mouthing, smelling, scratching, rubbing, visually scrutinizing objects or fingers close to eyes, placing ears against things that vibrate or hum, pressing objects against face)
_____ Tactile defensiveness (e.g., dislike being touched, touching certain things, wearing clothes, having face washed, teeth brushed, hair combed
_____ High tolerance for pain (e.g., not crying when hurt)
_____ Sleep disturbance (e.g., difficulty falling asleep, awaking early or during the night)
_____ Feeding disorder (e.g., limited food preferences, hypersensitivity to textures, retaining food in mouth, inconsistency in eating over time, pica – eating non-food substances)
_____ Possible developmental regression or slowing at approximately 1.5-3 years of age (e.g., loss of words)
_____Visual and motor skills higher than expressive and receptive language, especially for children with delayed development
_____ Expressive language disorder:
(1) no speech or absence of communicative speech with nonverbal communication at a higher level than verbal (e.g., pulling others by the
hand and leading to what wants) or:
(2) limited reciprocal conversational speech (versus communication in stress- and need-related situations, self-directed verbalizations, or
speaking on topics of interest to self)
_____ Atypical vocalizations such as unusual voice quality or modulation,
           screeching, odd noises, repetitive vocalizations, echolalia, idiosyncratic
           jargon or speech, perseverative speech, sporadic speech (e.g., uttering
           a word or phrase once and rarely or never saying it again), rote
           phrases out of context (from the past or videos), nonsensical speech,
           pronoun substitutions
_____ Splinter skills: specific abilities significantly above the child's mental
           age that often involve (1) rote memory (e.g., identification of numbers,
           letters, shapes, logos, and colours; singing or humming tunes;
           memorizing car routes; counting; saying the alphabet; reading;
           spelling; reciting segments from videos or books), (2) visual,
           manipulative, or mechanical skills (e.g., completing puzzles, matching
           shapes, using a computer or VCR), or (3) gross motor skills
_____ escape artist
_____ creates diversions and engages in self-selected activity

10. Actions and reactions

_____ Over-reactivity
_____ screaming
_____ irritability
_____ agitation
_____ tantrums
_____ self-injurious behavior
_____ distressed by input or occurrences most children can tolerate such as
           intrusions, activity interruptions, proximity, confinement, performance
           demands
_____ mood changes sometimes internally triggered such as becoming upset
           for no apparent reason
_____ laughing or hysterical laughter for no apparent reason
_____ Unresponsive in some situations
_____ Unusual fears (e.g., elevators, steps, toilets)
_____ Problems With Attention and Safety
_____ Selective attention
_____ hyper-focused on activities, objects, or topics of interest to self and
           inattentive at other times
_____ aggression
a.    bites
b.    pushes
c.    pinches
d.    scratches
e.    threatens with posture and eyes
f.    unpredictable

11. Physical characteristics

Skin colour_____________________________

Hair colour_____________________________

eye-colour_____________________________

eye-colour changes? ________________________________

_____ vitiligo (patches of skin with no pigment)

           describe:_________________________________________

                         _________________________________________

                         _________________________________________

           Other, describe:___________________________________

                        _________________________________________

                        ________________________________________

_____café-au-lait spots
_____birthmarks
_____freckle patterns on face
_____moles
_____rashes
           describe:________________________________________

                         ________________________________________

_____wheals _____psoriasis _____nodules _____purpura _____scars
_____ulcers _____erythema _____prurigo _____dyscrasia _____thrush
_____warts _____Blisters _____histyocytes _____folliculitis
_____Ridged nails _____nail spots
_____wide gap between big toe and second toe _____low set ears
_____large head circumference _____ear discharge

           describe:______________________________________

                         ________________________________________

                         ________________________________________
_____diarrhea
_____constipation
_____large stool, describe, colour__________________________

                       _________________________________________

                       _________________________________________

12. Background, culture (i.e. Irish, Asian, Afro Caribbean)

Mother_______________________________

Maternal grandmother____________________________

Maternal grandfather______________________________

Father_______________________________

Paternal grandmother____________________________

Paternal grandfather_____________________________

Diagnoses:
Autism Diagnosis:

Date:

Other (medical, mental health):


Development:

Birth i.e. normal or uncomplicated, C-section, suction:



Feeding- formula or breast milk?

Developmental Milestones (age):

__________sat up

__________crawled?

__________walked

__________vocalized

__________first words_______________________________________________

__________sang

__________repeated nursery rhymes

__________asked questions

__________reaches for objects


Dietary supplements:_____________________________________________

______________________________________________________________

_______________________________________________________________

Therapies received:______________________________________________

______________________________________________________________

______________________________________________________________________________________________________

Services available:_______________________________________________

______________________________________________________________

Services/therapies parents/guardians feel would benefit?______________________

______________________________________________________________

________________________________________________________________