1. How would your son/daughter react to quick bursts of sound at 100 dB.
(Sound level commensurate to a muffler backfire or high rim of a motorcycle)
____A. No reaction
____B. Grabs ears
____C. Screams, yells, runs or other overt reaction
2. Do large crowds bother your son/daughter
3. Does being hit by dirt or feeling dirty significantly affect your son/daughter’s personality?
4. Do bright lights agitate or frustrate your son/daughter?
5. Is your son/daughter extremely scared of the dark even when you are with him?
____ B. No
6. Has your son/daughter recently run away from you without apparent reason?
Required Answers: Question 1. Acceptable Answer 1 A and 1 B: Questions 2-6 No
Autistic Person’s Name/Age:________________________________________ ____
Signature of at least one of the custodial Parents:________________________________
Email the above to: firstname.lastname@example.org