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Autism assessment self referral form and Autism Spectrum Quotient (AQ)-50: Screening Questionnaire

Personal information

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Date of birth Required
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Address Required
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Are you an Armed Forces Veteran? Required
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AQ50

  • Read each of the statements very carefully
  • There are no right and wrong answers
  • Put a tick in the box to rate how strongly you agree or disagree with the statement
  • Do not miss out any statements
1. I prefer to do things with others rather than on my own Required
2. I prefer to do things the same way over and over again Required
3. If I try to imagine something, I find it very easy to create a picture in my mind Required
4. I frequently get so strongly absorbed in one thing that I lose sight of other things Required
5. I often notice small sounds when others do not Required
6. Other people frequently tell me that what I've said is impolite, even though I think it is polite Required
7. When I'm reading a story, I can easily imagine what the characters might look like Required
8. I am fascinated by dates Required
9. In a social group, I can easily keep track of several different people's conversations Required
10. I find social situations easy Required
11. I tend to notice details that others do not Required
12. I would rather go to a library than a party Required
13. I find making up stories easy Required
14. I find myself drawn more strongly to people than to things Required
15. I tend to have very strong interests which I get upset about if I can't pursue Required
16. I enjoy social chit-chat Required
17. When I talk, it isn't always easy for others to get a word in edgeways Required
18. I am fascinated by numbers Required
19. When I'm reading a story, I find it difficult to work out the characters' intentions Required
20. I don't particularly enjoy reading fiction Required
21. I find it hard to make new friends Required
22. I notice patterns in things all the time Required
23. I would rather go to the theatre than a museum Required
24. It does not upset me if my daily routine is disturbed Required
25. I frequently find that I don't know how to keep a conversation going Required
26. I find it easy to 'read between the lines' when someone is talking to me Required
27. I usually concentrate more on the whole picture, rather than the small details Required
28. I am not very good at remembering phone numbers Required
29. I like to plan any activities I participate in carefully Required
30. I don't usually notice small changes in a situation, or a person's appearance Required
31. I know how to tell if someone listening to me is getting bored Required
32. I find it easy to do more than one thing at a time Required
33. When I talk on the phone, I'm not sure when it's my turn to speak Required
34. I enjoy doing things spontaneously Required
35. I am often the last to understand the point of a joke Required
36. I find it easy to work out what someone is thinking or feeling just by looking at their face Required
37. If there is an interruption, I can switch back to what I was doing very quickly Required
38. I am good a social chit-chat Required
39. People often tell me that I keep going on and on about the same thing Required
40. When I was young, I used to enjoy playing games involving pretending with other children Required
41. I like to collect information about categories of things (e.g. types of cars, birds, trains, plants, etc.) Required
42. I find it difficult to imagine what it would be like to be someone else Required
43. I enjoy social occasions Required
44. I find it difficult to work out people's intentions Required
45. New situations make me anxious Required
46. I enjoy meeting new people Required
47. I am a good diplomat Required
48. I am not very good at remembering people's dates of birth Required
49. I am not very good at remembering people's dates of birth Required
50. I find it very easy to play games with children that involve pretending Required
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Next steps

Once we receive your referral, the AQ50 will be scored and your clinical information will be reviewed. If it meets our criteria to be offered an NHS assessment you will be sent a number of questionnaires to complete to aid the assessment process. Please note: It is important that you complete and return these questionnaires.  We can offer reasonable adjustments for people who struggle with filling in forms.

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