Patient Name: Jane Doe Test Name: Coolidge Autistic Symptoms Survey
Gender: Female Test Date: Mar 12, 2016
Patient Age: 33 Data Provided By: mother
Profile Validity
Answer Frequency (response pattern):
Raw Scores:
1 = Strongly False (SF) 8 32.8 (13.5)
2 = More False Than True (MF) 22 22.8 (9.4)
3 = More True Than False (MT) 20 11.3 (6.8)
4 = Strongly True (ST) 7 2.9 (3.8)
1. Inappropriate body language/gestures 1 29. Difficulty with common expressions 2 57. Dislikes transition/changes 2
2. Talks less than other children 2 30. Moves fingers in front of face 3 58. Inappropriate facial expressions 3
3. Emotionally cold/detached 3 31. Doesn't interact well with children 2 59. Play with certain toys 2
4. Unable to give eye messages 4 32. Difficulty with eye contact 3 60. Trouble with conversations 2
5. Misuses pronouns 3 33. Misinterprets what others say 1 61. Talks only about self-interests 3
6. Repeats what is said 2 34. Trouble understanding feelings of others 4 62. Different sense of humor 3
7. Doesn't laugh at jokes 1 35. Strange/unusual speech rhythm/inflection 3 63. Sensitive to lights/sounds/tastes/touch/smells 3
8. No close friends. 2 36. Limited interests 2 64. Insensitive to lights/sounds/tastes/touch/smells 2
9. Stops thoughts if interrupted 3 37. Limited gestures 2 65. Sounds like dictionary/encyclopedia 1
10. Potty trained late 4 38. Difficulty approaching children 3 66. Rocks back/forth 2
11. Laughs for unknown reasons 3 39. Trouble hugging/kissing 2 67. Comes too close when talking 3
12. Trouble playing like other children 2 40. Won't look if I point 2 68. Talks too much only specific topics 4
13. Prefers things same old way 1 41. Difficult starting friendships 1 69. Trouble following conversations 3
14. Trouble reading facial expressions 2 42. Doesn't respond to own name 2 70. Neither speaks/communicates/points 3
15. Intense dislike of change. 3 43. Misinterprets body language/gestures 3 71. Sensitive to bright light 2
16. Repeats words/phrases 4 44. Uncoordinated/clumsy 4 72. No response to flashing lights 2
17. Tries to engage with children but fails 3 45. Intense interest in a single subject 3 73. Sensitive to loud noises 3
18. Trouble using hands for expression 3 46. Preoccupied with object parts 2 74. No respond to loud noises 4
19. Loner 2 47. Tolerates only little physical contact 1 75. Constant need to touch certain things 3
20. Strange/weird or no handshake 2 48. Fascination with fans/spinning objects 2 76. Cannot be touched 2
21. Unaware of body language 2 49. Brings me things that interested in 3 77. Indifferent to smells 1
22. Doesn't look at others when talking 3 50. Difficult to read child's feelings 2 78. Interest with smelling certain things 2
23. Drags toes when walking 4 51. Limited facial expressions 1 79. Only eats certain foods 3
24. Doesn't notice people 3 52. Delayed speech 2 80. Unresponsive to food tastes 4
25. Only points out things that interested in 2 53. Approaches only when needs 3 81. Sensitive to extreme temperatures 3
26. Flaps arms/hands 2 54. Socially clumsy or awkward 4 82. Not sensitive to extreme temperatures 3
27. Trouble expressing self 2 55. Avoid activities involving children 3 83. Wanders away without permission 2
28. Physically inappropriate with children 1 56. Fixed routine/rules, angry/upset at change 2 84. Overly fearful or lacks fear 2
Patient Name: Jane Doe Test Name: Coolidge Autistic Symptoms Survey
Gender: Female Test Date: Mar 12, 2016
Patient Age: 33 Data Provided By: mother
Scale %tile TScore 10 20 30 40 50 60 70 80 90 100
Overall ASD 24% 43
A: Persistent Deficits in Social Communication/Interaction (PDSCI) 15% 39
A1: Deficits in Social-Emotional Reciprocity (DSER) 16% 40
A2: Deficits in Nonverbal Communication (DNVC) 16% 40
A3: Deficits in Relationships (DR) 11% 37
B. Restricted, Repetitive Patterns of Behavior (RRPB) 44% 48
B1: Stereotyped/Repetitive Motor Movements 85% 60
B2: Insistence on Sameness (IS) 2% 29
B3: Restricted/Fixated Interests (RFI) 6% 34
B4: Hyper-Hypo Reactivity to Environment (HHRE) 83% 60
Patient Name: Jane Doe Test Name: Coolidge Autistic Symptoms Survey
Gender: Female Test Date: Mar 12, 2016
Patient Age: 33 Data Provided By: mother

A. Persistent Deficits in Social Communication/Interaction (PDSCI):
A1: Deficits in Social-Emotional Reciprocity (DSER)
mostly true3.My child seems emotionally cold or detached.
mostly true9.My child stops her/his train of thought if interrupted.
mostly true17.My child tries to engage with other children, but doesn't seem to know how.
strongly true34.My child has trouble understanding the feelings of others.
mostly true53.My child approaches others only when he/she needs something for himself/herself.
mostly true61.My child has no trouble starting conversations, but only about things he or she wishes to talk about.
mostly true67.When talking to others, my child comes up too close to other people.
strongly true68.My child talks too much, but only on specific topics.
mostly true69.My child has trouble following conversations.
mostly true70.My child neither speaks, nor tries to communicate through other means (for examples, pointing).
A2: Deficits in Nonverbal Communication (DNVC)
strongly true4.My child is unable to give messages with his or her eyes (e.g., rolls her/his eyes in annoyance).
mostly true18.My child has trouble using his or her hands to express himself or herself (e.g., doesn't use hands when talking, doesn't give high fives or does so inappropriately, doesn't fist-bump or does so inappropriately).
mostly true22.I have to remind my child to look at me or other people when talking to them.
mostly true32.My child has difficulty making or maintaining eye contact.
mostly true35.My child has a strange or unusual rhythm or inflection when he/she speaks.
mostly true43.My child misunderstands certain body language or gestures.
strongly true44.My child is uncoordinated or clumsy (e.g., riding a bike or running).
mostly true58.My child has inappropriate or exaggerated facial expressions (e.g., blank stares, little emotion, grimaces).
A3: Deficits in Relationships (DR)
mostly true11.My child laughs for reasons I don't understand.
mostly true24.My child seems to not notice other people, even if they are in the same room.
mostly true38.Even when my child tries to approach other children, he/she finds it difficult.
mostly true49.My child brings me things that he/she is interested in
strongly true54.My child is socially clumsy or awkward.
mostly true55.My child tends to avoid activities involving other children.
mostly true62.My child has a different sense of humor from other kids (e.g. only laughs at puns, only when people get hurt).
B. Restricted, Repetitive Patterns of Behavior (RRPB):
B1: Stereotyped/Repetitive Motor Movements
mostly true5.My child misuses pronouns like substituting "I" for "you," "him" for "me," or "her" for "me."
strongly true16.My child repeats the same word or phrase a lot.
strongly true23.My child drags his/her toes often when walking.
mostly true30.My child often moves his/her fingers quickly in front of his/her face.
B2: Insistence on Sameness (IS)
strongly true10.My child potty trained later than most children her/his age.
mostly true15.My child has an intense dislike of change.
B3: Restricted/Fixated Interests (RFI)
mostly true45.My child gets intensely interested or preoccupied with a single subject and doesn't seem to want to do anything else (e.g., trains, vacuum cleaners, firetrucks, planes, details of plane wrecks, details of major accidents or natural disasters, Anime [Japanese cartoons] or other cartoon figures, and the Titanic).
B4: Hyper-Hypo Reactivity to Environment (HHRE)
mostly true63.My child is overly sensitive to lights, sounds, tastes, touch, or smells.
mostly true73.My child is very sensitive to loud noises.
strongly true74.My child does not seem to respond to loud noises as he/she should.
mostly true75.My child seems to have a constant need to touch certain things.
mostly true79.My child will only eat certain foods because of the taste.
strongly true80.My child seems unresponsive to tastes of food.
mostly true81.My child seems excessively sensitive to extreme temperatures outside.
mostly true82.My child is not sensitive to extreme hot or cold temperatures.