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Autism Treatment Evaluation Checklist (301926-DT)

Autism Treatment Evaluation Checklist (301926-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

Patient Name


MR #

Index to Autism Therapy\Encounter

UWH301926-DT (Rev. 03/27/17) Autism Treatment Evaluation Checklist (ATC)
Page 1 of 1
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)


Please circle the letters to indicate how true each phrase is:
I. Speech/Language/Communication [ N ] Not true [ S ] Somewhat true [ V ] Very true

N S V 1. Knows own name N S V 6. Can use 3 words at a time
(Want more milk)
N S V 11. Speech tends to be meaningful/
relevant N S V 2. Responds to “No” or “Stop”
N S V 3. Can follow some commands N S V 7. Knows 10 or more words N S V 12. Often uses several successive
N S V 4. Can use one word at a time N S V 8. Can use sentences with 4 or sentences

(No!, Eat, Water, etc.) more words N S V 13. Carries on fairly good
N S V 5. Can use 2 words at a time N S V 9. Explains what he/she wants conversation

(Don’t want, Go home) N S V 10. Asks meaningful questions N S V 14. Has a normal ability to
communicate for his/her age.

II. Sociability [ N ] Not true [ S ] Somewhat true [ V ] Very true
N S V 1. Seem to be in a shell - you N S V 7. Show no affection N S V 14. Disagreeable/not compliant
cannot reach him/her
N S V 2. Ignores other people N S V 8. Fails to greet parents N S V 15. Temper tantrums
N S V 3. Pays little or no attention N S V 9. Avoids contact with others N S V 16. Lacks friends/companions
when addressed N S V 10. Does not imitate N S V 17. Rarely smiles
N S V 4. Uncooperative and resistant N S V 11. Dislikes being held/cuddled N S V 18. Insensitive to other’s feelings
N S V 5. No eye contact N S V 12. Does not share or show N S V 19. Indifferent to being liked
N S V 6. Prefers to be left alone N S V 13. Does not wave “bye bye” N S V 20. Indifferent if parents(s) leave
III Sensory/Cognitive Awareness: [ N ] Not true [ S ] Somewhat true [ V ] Very true
N S V 1. Responds to own name N S V 7. Appropriate facial expression N S V 13. Initiates activities
N S V 2. Responds to praise N S V 8. Understands stories on T.V. N S V 14. Dresses self
N S V 3. Looks at people and animals N S V 9. Understands explanations N S V 15. Curious, interested
N S V 4. Looks at pictures (and T.V.) N S V 10. Aware of environment N S V 16. Venturesome-explores
N S V 5. Does drawing, coloring, art N S V 11. Aware of danger N S V 17. “Tuned in”- Not spacey
N S V 6. Plays with toys appropriately N S V 12. Shows imagination N S V 18. Looks where others are

IV Health/Physical /Behavior [ N ] Not true [ S ] Somewhat true [ V ] Very true
N S V 1. Bed-wetting N S V 9.
N S V 18. Obsessive speech
N S V 2. Wets pants/diapers N S V 10.
N S V 19. Rigid routines
N S V 3. Soil pants/diapers N S V 11.
Hits or injuries self
N S V 20. Shouts or screams
N S V 4. Diarrhea N S V 12.
Hits or injuries others
N S V 21. Demands sameness
N S V 5. Constipation N S V 13.
N S V 22. Often agitated
N S V 6. Sleep problems N S V 14.
N S V 23. Not sensitive to pain
N S V 7. Eats to much /too little N S V 15.
N S V 24. “Hooked” or fixed on
N S V 8. Extremely limited diet N S V 16.

certain objects/topics
N S V 17. Seizures N S V 25. Repetitive movements
(stimming, rocking, ect.)

Copyright (c) 2016 Stephen M. Edelson Autism Research Institute all Rights Reserved. The Autism Treatment Evaluation Checklist (ATEC) May Be Used
Only For Non-Commercial Purposes

Signature of Patient/Representative _________________________________Date:__________Time:________AM/PM

If signed by person other than the patient, print name and state relationship and authority to do so.

Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________

Reviewed by: ___________________________________________________ Date: _____________Time: __________ AM/PM