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Q.1
Is your child often late for school in the morning because you can’t get him out of the shower or the bathroom?
*
Yes – frequently
Sometimes
No – never
Q.2
When relatives come to visit, does your child avoid being hugged at all costs?
*
Yes – frequently
Sometimes
No – never
Q.3
Do you have to plan short outings because your child refuses to use public bathrooms?
*
Yes – frequently
Sometimes
No – never
Q.4
Has your child ever revealed fears that her family is in danger?
*
Yes – frequently
Sometimes
No – never
Q.5
When you are leaving the house for the day, does your child double back to make sure the door is locked?
*
Yes – frequently
Sometimes
No – never
Q.6
Does your child have a precious collection of items anyone else would consider trash, like lollipop wrappers or bottle caps?
*
Yes
No
Q.7
Even when he seems well, does your child ask you to take his temperature to make sure he’s not sick?
*
Yes – frequently
Sometimes
No – never
Q.8
Does your child refuse to share her toys for fear of contamination from siblings or friends?
*
Yes – frequently
Sometimes
No – never
Q.9
Does your child insist on completing a specific sequence before bed night, and does he become agitated if something interrupts it?
*
Yes – frequently
Sometimes
No – never
Q.10
During homework time, does your child erase sentences and rewrite them over and over until they are “just right”?
*
Yes – frequently
Sometimes
No – never
Q.11
Is your child extremely slow when getting dressed, completing chores, or doing schoolwork?
*
Yes – frequently
Sometimes
No – never
Q.12
Does your child have an unusual interest in religious observances and saying prayers over and over?
*
Yes – frequently
Sometimes
No – never
Q.13
Are there certain jersey numbers your child refuses to wear because they are unlucky or unsafe?
*
Yes
No
Q.14
When playing with an electronic toy, does your child switch it on and off over and over?
*
Yes – frequently
Sometimes
No – never
Q.15
At dinnertime, has your child ever asked if the food has gone bad or suggested it was poisoned?
*
Yes – frequently
Sometimes
No – never
Q.16
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