Autism Spectrum Quotient (AQ)
Provided by: Wellness Grove
Client Legal Name
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First Name
Middle Name
Last Name
Client Preferred Name
Client Date of Birth
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Month
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Day
Year
Client Last 4 of SS#
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Client Email Address
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Confirmation Email
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Name of Individual Completing the Client Packet (Adult) (if not the client)
First Name
Last Name
Relationship to the client (if not the client)
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BEGIN
AQ
For each statement below, choose one response that best describes how strongly that statement applies to you.
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Definitely Agree
Slightly Agree
Slightly Disagree
Definitely Disagree
1. I prefer to do things with others, rather than on my own.
2. I prefer to do things the same way over and over again.
3. If I try to imagine something, I find it very easy to create a picture in my mind.
4. I frequently get so strongly absorbed in one thing that I lose sight of other things.
5. I often notice small sounds when others do not.
6. I usually notice car number plates or similar strings of information.
7. Other people frequently tell me that what I’ve said is impolite, even though I think it is polite.
8. When I’m reading a story, I can easily imagine what the characters might look like.
9. I am fascinated by dates.
10. In a social group, I can easily keep track of several different people’s conversations.
11. I find social situations easy.
12. I tend to notice details that others do not.
13. I would rather go to a library than to a party.
14. I find making up stories easy.
15. I find myself drawn more strongly to people than to things.
16. I tend to have very strong interests, which I get upset about if I can’t pursue.
17. I enjoy social chitchat.
18. When I talk, it isn’t always easy for others to get a word in edgewise.
19. I am fascinated by numbers.
20. When I’m reading a story, I find it difficult to work out the characters’ intentions.
21. I don’t particularly enjoy reading fiction.
22. I find it hard to make new friends.
23. I notice patterns in things all the time.
24. I would rather go to the theatre than to a museum.
25. It does not upset me if my daily routine is disturbed.
26. I frequently find that I don’t know how to keep a conversation going.
27. I find it easy to ‘read between the lines’ when someone is talking to me.
28. I usually concentrate more on the whole picture, rather than on the small details.
29. I am not very good at remembering phone numbers.
30. I don’t usually notice small changes in a situation or a person’s appearance.
31. I don’t know how to tell if someone listening to me is getting bored.
32. I find it easy to do more than one thing at once.
33. When I talk on the phone, I’m not sure when it’s my turn to speak.
34. I enjoy doing things spontaneously.
35. I am often the last to understand the point of a joke.
36. I find it easy to work out what someone is thinking or feeling just by looking at their face.
37. If there is an interruption, I can switch back to what I was doing very quickly.
38. I am good at social chitchat.
39. People often tell me that I keep going on and on about the same thing.
40. When I was young, I used to enjoy playing games involving pretending with other children.
41. I like to collect information about categories of things (e.g. types of cars, birds, trains, plants).
42. I find it difficult to imagine what it would be like to be someone else.
43. I like to carefully plan any activities I participate in.
44. I enjoy social occasions.
45. I find it difficult to work out people’s intentions.
46. New situations make me anxious.
47. I enjoy meeting new people.
48. I am a good diplomat.
49. I am not very good at remembering people’s date of birth.
50. I find it very easy to play games with children that involve pretending.
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Acknowledge & Sign
By signing this form electronically and clicking on "Sign & Submit", you are certifying that the information given on this form is true and correct to the best of your knowledge. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.
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Client/Representative Legal Name
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Date
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Month
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Day
Year
If Parent/Guardian/Legal Representative, please describe your relationship to the client
Sign & Submit
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