Mowat-Wilson Behavioral Survey Page
www.mowatwilson.org
Results will be posted on the Survey Results Page of this Website
Please answer all the questions to the best of you knowledge, if not sure of an exact
answer, please enter you best guess.

Has your child had a formal IQ or developmental assessment?    Yes    No

If yes, what level of intellectual disability does your child have?    Mild Moderate Severe Profound

Can your child sit up on their own?    Age Inappropriate A/I Yes No

If yes, at what age were they able to do so?    Age Inappropriate A/I 6-12 mo 13-18mo 19-24 mo 25-30 mo 31-36 mo 37-42 mo 43-48 mo

Does your child walk independently?    Age Inappropriate A/I No Yes

If Yes, do they walk with an unusual gait?    Select One Age Inappropriate A/I Does Not Walk N/A Yes No

If No, do they walk with?    N/A Walks With a Walker Assistance Do Not Because of Physical Limitation Age Inappropriate A/I

At what age did they cruise?    Age Inappropriate A/I N/A Does Not Walk 6-12 mo 13-18 mo 19-24 mo 25-30 mo 31-36 mo 37-42 mo 42 mo or older

At what age did they begin to walk independently?    Select One Age Inappropriate A/I Does Not Walk 24-30 mo 31-36 mo 37-42 mo 43-48 mo 49-56 mo 57-62 mo 62 mo or Older

Does your child speak?    Age Inappropriate A/I Yes No

If yes, how many words? (apx)    Non Verbal 12 or Less 12 to 40 40 or Greater

If yes, at what age did they begin to speak?    Select One Age Inappropriate Non-Verbal 36-42 mo 43-48 mo 49-56 mo 57-62 mo 63-68 mo 69-74 mo 75 mo or Older

If no, do they use any other means of communication and what form?    Select One Age Inappropriate A/I Picture Exchange Signing Pointing Combination of All Other

Have you attempted toilet training?    Age Inappropriate A/I Ostomy-Does not apply S/R Yes No

If yes, what results have you had?    None Ostomy-Does not apply S/R Timed During The Day Fully Trained

Does your child have regular bowel movements?    Ostomy-Does not apply S/R Yes No

Does your child feed themselves independently?    Age Inappropriate A/I With Some Assistance Yes No

Does your child dress themselves?    Age Inappropriate A/I Yes No With Some Assistance

Does your child sleep through the night?   Yes    No

Please choose from the drop down lists the answer for each of the following items that best applies to your child.

Tends to be shy    Not Typical Somewhat Typical Very Typical

Cries easily    Not Typical Somewhat Typical Very Typical

Likes to be with other people    Not Typical Somewhat Typical Very Typical

Is always on the go    Not Typical Somewhat Typical Very Typical

Prefers playing with others rather than alone    Not Typical Somewhat Typical Very Typical

Tends to be a loner    Not Typical Somewhat Typical Very Typical

Makes friends easily    Not Typical Somewhat Typical Very Typical

Is off and running as soon as they awake in the morning    Not Typical Somewhat Typical Very Typical

Is very sociable    Not Typical Somewhat Typical Very Typical

Is very energetic    Not Typical Somewhat Typical Very Typical

Takes a long time to warm to strangers    Not Typical Somewhat Typical Very Typical

Is very friendly with strangers    Not Typical Somewhat Typical Very Typical

Is somewhat of a loner    Not Typical Somewhat Typical Very Typical

Gets upset easily    Not Typical Somewhat Typical Very Typical

Reacts intensely when upset    Not Typical Somewhat Typical Very Typical

Hits or bites their self.    Never Sometimes Often

Impulsive, acts before thinking    Not Typical Somewhat Typical Very Typical

Noisy and boisterous    Never Sometimes Often

Poor sense of danger    Not Typical Somewhat Typical Very Typical

Repeated movements of hands, body, head, hand flapping or rocking    Never Sometimes Often

Resists being cuddled, touched or held    Not Typical Somewhat Typical Very Typical

Screams a lot    Never Sometimes Often

Avoids eye contact    Not Typical Somewhat Typical Very Typical

Bangs head    Never Sometimes Often

Bites or pinches others    Never Sometimes Often

Chews or mouths objects    Never Sometimes Often

Fussy eater    Not Typical Somewhat Typical Very Typical

Grinds teeth    Never Sometimes Often

Sleeps too little    Not Typical Somewhat Typical Very Typical

Sleeps too much    Not Typical Somewhat Typical Very Typical

Submitter Name                *Required Field

Submitters Email Address                   *Required Field

Childs First Name                   *Required Field

Thank you for filling out a survey. There is also an Associated Condition survey for MWS.
You can participate in that survey by clicking here. Associate Condition Survey Page.
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