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.

Childs Age   

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

If yes, what level of intellectual disability does your child have?   

Can your child sit up on their own?   

If yes, at what age were they able to do so?   

Does your child walk independently?   

If Yes, do they walk with an unusual gait?   

If No, do they walk with?   

At what age did they cruise?   

At what age did they begin to walk independently?   

Does your child speak?   

If yes, how many words? (apx)   

If yes, at what age did they begin to speak?   

If no, do they use any other means of communication and what form?   

Have you attempted toilet training?   

If yes, what results have you had?   

Does your child have regular bowel movements?   

Does your child feed themselves independently?   

Does your child dress themselves?   

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   

Cries easily   

Likes to be with other people   

Is always on the go   

Prefers playing with others rather than alone   

Tends to be a loner   

Makes friends easily   

Is off and running as soon as they awake in the morning   

Is very sociable   

Is very energetic   

Takes a long time to warm to strangers   

Is very friendly with strangers   

Is somewhat of a loner   

Gets upset easily   

Reacts intensely when upset   

Hits or bites their self.   

Impulsive, acts before thinking   

Noisy and boisterous   

Poor sense of danger   

Repeated movements of hands, body, head, hand flapping or rocking   

Resists being cuddled, touched or held   

Screams a lot   

Avoids eye contact   

Bangs head   

Bites or pinches others   

Chews or mouths objects   

Fussy eater   

Grinds teeth   

Sleeps too little   

Sleeps too much   

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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