Module 5

Module 5 – Behaviour and Development

Moico Module 5 Alt
This module is completed when entering the patient registry and updated annually for children under ten then every two years. This module collects information on gross and fine motor, adaptive behaviours, activities and other behaviours.
5a.1 Please describe these types of muscle tone (ANGMuscleTone)
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5a.1.1ANGBEHDEVMuscleTrunkHow would you describe your child/ adult’s muscle tone?1 – Low;
2 – Medium;
3 – High;
4 – Mixed
5a.1.2ANGBEHDEVMuscleTrunk2How would you describe your child/ adult’s muscle tone in his/her trunk?
Trunk includes the neck, back and stomach.
1 – Low;
2 – Medium;
3 – High;
4 – Mixed
5a.1.3ANGBEHDEVMuscleLimbsHow would you describe your child/ adult’s muscle tone in his/her limbs?
Limbs includes the arms/ hands and legs/ feet
1 – Low;
2 – Medium;
3 – High;
4 – Mixed

 

5a.2. Current Development: General Impressions (ANGBEHDEVGENERALIMPRESSION)
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5a.2.1ANGBEHDEVGENIMPRESSTick which best applies to your child/ adult’s ability to learn1 – Continues to learn new things;
2 –Learning is static;
3 Lost some skills in the last year.
5a.2.2ANGBEHDEVLOSTWHATIf they have lost significant skills, what skills have they lost?1 – Speech;
2 – Understanding;
3 – Motor
5a.2.3ANGBEHDEVLOSTMOTORWhat motor skills? (Check all that apply)1 – Walking;
2 – Dressing;
3 – Feeding;
4 – Other
5a.2.4ANGBEHDEVLOSTMOTOROTHPlease describe 

 

5a.3 Other comments (ANGGENERALCOMMENTSec)
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5a.3.1ANGGENERALCOMMENTAny other comments about your child/ adult’s development? 

 

5b.1 Current Development: Gross Motor function (ANGBEHDEVMOTORFUNCTION)
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5b.1.1ANGBEHDEVMOBILITYBESTPlease indicate the individual with Angelman Syndrome’s best mobility1 – Can’t mobilise;
2 – Rolls across floor;
3 – Crawls;
4 – Shuffles/scoots along seated;
5 – Stands supported but not mobilising;
6 – Stands alone with minimal support;
7 – Stands alone;
8 – Mobilises walking with support;
9 – Mobilises walking with minimal support;
10 – Walks independently but loses balance occasionally;
11 – Walks but very unsteady;
12 – Walks with stable gait;
13 – Runs independently;
14 – Climbs stairs (alternating foot over foot);
15 – Jumps ((Range/
5b.1.2ANGBEHDEVMOBILITYSUPPORTIf they use support, what form of support do they use? (Check all that apply)1 – Walking frame (walker and gait trainer);
2 – Wheelchair for long distances;
3 – Wheelchair for all mobilisation
5b.1.3ANGBEHDEVTYPICALGAITWould you describe your child/ adult’s gait as typical when compared to the typically developing age matched peers?1 – Yes;
2 – No;
3 – Unknown
5b.1.4ANGBEHDEVATYPGAITPlease describe your child/ adult’s gait1 – Broad based/ wide;
2 – Lopsided;
3 – Jerky;
4 – Frequent falls;
5 – Gets tired;
6 – Walks on toes;
7 – Walks with knees bent (crouched);
8 – Walks with feet turned in;
9 – Walks with feet turned out
5b.1.5ANGBEHDEVGAITWould you describe their gait as:1 – Getting better;
2 – Stable;
3 – Getting worse
5b.1.6ANGBEHDEVGAITWORSEPlease describe 

 

5b.2 Gross Motor Function – please describe your child/adult’s ability to do the following: (GROSSMOTOR)
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5b.2.1aANGGROSSMOTORROLLABILITYLRoll across the floor1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.1bANGGROSSMOTORROLLABILITYDKOr, don’t know 
5b.2.1cANGGROSSMOTORROLLFREQLAnd frequency 
5b.2.1dANGGROSSMOTORROLLAGELAnd age? (Age first performed activity) 
5b.2.2aANGGROSSMOTORSITABILITYLSit up1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.2bANGGROSSMOTORSITABILITYDKOr, don’t know 
5b.2.2cANGGROSSMOTORSITFREQLAnd frequency 
5b.2.2dANGGROSSMOTORSITAGELAnd age? (Age first performed activity) 
5b.2.3aANGGROSSMOTORCRAWLABILITYLCrawl1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.3bANGGROSSMOTORCRAWLABILITYDKOr, don’t know 
5b.2.3cANGGROSSMOTORCRAWLFREQLAnd frequency 
5b.2.3dANGGROSSMOTORCRAWLAGELAnd age? (Age first performed activity) 
5b.2.4aANGGROSSMOTORSHUFFLEABILITYLShuffles or scoots when seated1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.4bANGGROSSMOTORSHUFFLEABILITYDKOr, don’t know 
5b.2.4cANGGROSSMOTORSHUFFLEFREQLAnd frequency 
5b.2.4dANGGROSSMOTORSHUFFLEAGELAnd age? (Age first performed activity) 
5b.2.5aANGGROSSMOTORSTANDABILITYLStand up1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.5bANGGROSSMOTORSTANDABILITYDKOr, don’t know 
5b.2.5cANGGROSSMOTORSTANDFREQLAnd frequency 
5b.2.15dANGGROSSMOTORSTANDAGELAnd age? (Age first performed activity) 
5b.2.6aANGGROSSMOTORWALKABILITYLWalk (unassisted)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.6bANGGROSSMOTORWALKABILITYDKOr, don’t know 
5b.2.6cANGGROSSMOTORWALKFREQLAnd frequency 
5b.2.6dANGGROSSMOTORWALKAGELAnd age? (Age first performed activity) 
5b.2.7aANGGROSSMOTORRUNABILITYLRun1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.7bANGGROSSMOTORRUNABILITYDKOr, don’t know 
5b.2.7cANGGROSSMOTORRUNFREQLAnd frequency 
5b.2.7dANGGROSSMOTORRUNAGELAnd age? (Age first performed activity) 
5b.2.8aANGGROSSMOTORSTAIRSABILITYLClimb stairs1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.8bANGGROSSMOTORSTAIRSABILITYDKOr, don’t know 
5b.2.8cANGGROSSMOTORSTAIRSFREQLAnd frequency 
5b.2.8dANGGROSSMOTORSTAIRSAGELAnd age? (Age first performed activity) 
5b.2.9aANGGROSSMOTORJUMPABILITYLJump1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.2.9bANGGROSSMOTORJUMPABILITYDKOr, don’t know 
5b.2.9cANGGROSSMOTORJUMPFREQLAnd frequency 
5b.2.9dANGGROSSMOTORJUMPAGELAnd age? (Age first performed activity) 

 

5.3 Fine Motor Function – please describe your child/adult’s ability to do the following: (FINEMOTOR)
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5b.3.1aANGFINEMOTORHOLDABILITYLHold things, such as a stuffed toy1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.1bANGFINEMOTORHOLDABILITYDKOr, don’t know 
5b.3.1cANGFINEMOTORHOLDFREQLAnd frequency 
5b.3.1dANGFINEMOTORHOLDAGELAnd age? (Age first performed activity) 
5b.3.2aANGFINEMOTORPOINTABILITYLPoint to indicate things1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.2bANGFINEMOTORPOINTABILITYDKOr, don’t know 
5b.3.2cANGFINEMOTORPOINTFREQLAnd frequency 
5b.3.2dANGFINEMOTORPOINTAGELAnd age? (Age first performed activity) 
5b.3.3aANGFINEMOTORTRANSFERABILITYLTransfer things between hands1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.3bANGFINEMOTORTRANSFERABILITYDKOr, don’t know 
5b.3.3cANGFINEMOTORTRANSFERFREQLAnd frequency 
5b.3.3dANGFINEMOTORTRANSFERAGELAnd age? (Age first performed activity) 
5b.3.4aANGFINEMOTORPENCILABILITYLHold a pencil and scribble1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.4bANGFINEMOTORPENCILABILITYDKOr, don’t know 
5b.3.4cANGFINEMOTORPENCILFREQLAnd frequency 
5b.3.4dANGFINEMOTORPENCILAGELAnd age? (Age first performed activity) 
5b.3.5aANGFINEMOTORDRAWABILITYLHold a pencil and draw1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.5bANGFINEMOTORDRAWABILITYDKOr, don’t know 
5b.3.5cANGFINEMOTORDRAWFREQLAnd frequency 
5b.3.5dANGFINEMOTORDRAWAGELAnd age? (Age first performed activity) 
5b.3.6aANGFINEMOTORLARGEBALLABILITYLCatch a large ball1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.6bANGFINEMOTORLARGEBALLABILITYDKOr, don’t know 
5b.3.6cANGFINEMOTORLARGEBALLFREQLAnd frequency 
5b.3.6dANGFINEMOTORLARGEBALLAGELAnd age? (Age first performed activity) 
5b.3.7aANGFINEMOTORSMALLABILITYLCatch a small ball1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5b.3.7bANGFINEMOTORSMALLABILITYDKOr, don’t know 
5b.3.7cANGFINEMOTORSMALLFREQLAnd frequency 
5b.3.7dANGFINEMOTORSMALLAGELAnd age? (Age first performed activity) 

 

5b.4 Other comments (ANGMOTORCOMMENTSec)
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5b.4.1ANGMOTORCOMMENTAny other comments about your child/ adult’s motor function? 

 

5c.1. Adaptive Skills – Dressing – please describe your child/adult’s ability to do the following: (ANGADAPTBEHDRESS)
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5c.1.1aANGDRESSPUTUPHANDSABILITYLPut up their hands to help dress1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.1bANGDRESSPUTUPHANDSABILITYDKOr, don’t know 
5c.1.1cANGDRESSPUTUPHANDSFREQLAnd frequency 
5c.1.1dANGDRESSPUTUPHANDSAGELAnd age? (Age first performed activity) 
5c.1.2aANGDRESSREMOVESIMPLEABILITYLTake off simple clothes such as socks1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.2bANGDRESSREMOVESIMPLEABILITYDKOr, don’t know 
5c.1.2cANGDRESSREMOVESIMPLEFREQLAnd frequency 
5c.1.2dANGDRESSREMOVESIMPLEAGELAnd age? (Age first performed activity) 
5c.1.3aANGDRESSREMOVECOMPLEXABILITYLTake off complex clothes such as shirts1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.3bANGDRESSREMOVECOMPLEXABILITYDKOr, don’t know 
5c.1.3cANGDRESSREMOVECOMPLEXFREQLAnd frequency 
5c.1.3dANGDRESSREMOVECOMPLEXAGELAnd age? (Age first performed activity) 
5c.1.4aANGFINEMOTORVELCROABILITYLDo up velcro1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.4bANGFINEMOTORVELCROABILITYDKOr, don’t know 
5c.1.4cANGFINEMOTORVELCROFREQLAnd frequency 
5c.1.4dANGFINEMOTORVELCROAGELAnd age? (Age first performed activity) 
5c.1.5aANGFINEMOTORBUTTONABILITYLDo up buttons or zippers1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.5bANGFINEMOTORBUTTONABILITYDKOr, don’t know 
5c.1.5cANGFINEMOTORBUTTONFREQLAnd frequency 
5c.1.5dANGFINEMOTORBUTTONAGELAnd age? (Age first performed activity) 
5c.1.6aANGDRESSSELFERRORABILITYLDress themselves, even if not always right (eg buttons not lined up, clothes back to front)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.6bANGDRESSSELFERRORABILITYDKOr, don’t know 
5c.1.6cANGDRESSSELFERRORFREQLAnd frequency 
5c.1.6dANGDRESSSELFERRORAGELAnd age? (Age first performed activity) 
5c.1.7aANGDRESSSELFOKABILITYLDress themselves without assistance1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.7bANGDRESSSELFOKABILITYDKOr, don’t know 
5c.1.7cANGDRESSSELFOKFREQLAnd frequency 
5c.1.7dANGDRESSSELFOKAGELAnd age? (Age first performed activity) 
5c.1.8aANGDRESSAPPRPRIATEABILITYLChooses clothes appropriately (eg warm clothes if cold)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.1.8bANGDRESSAPPRPRIATEABILITYDKOr, don’t know 
5c.1.8cANGDRESSAPPRPRIATEFREQLAnd frequency 
5c.1.8dANGDRESSAPPRPRIATEAGELAnd age? (Age first performed activity) 

 

5c.2. Adaptive Skills – Toileting and Continence – please describe your child/adult’s ability to do the following: (ANGADAPTBEHTOILETING)
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5c.2.1aANGTOILETCONTINENTABILITYLIs continent (toilet trained)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.1bANGTOILETCONTINENTABILITYDKOr, don’t know 
5c.2.1cANGTOILETCONTINENTFREQLAnd frequency 
5c.2.1dANGTOILETCONTINENTAGELAnd age? (Age first performed activity 
5c.2.2aANGTOILETBEHABILITYLShowed indications of toileting behaviours1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.2bANGTOILETBEHABILITYDKOr, don’t know 
5c.2.2cANGTOILETBEHFREQLAnd frequency 
5c.2.2dANGTOILETBEHAGELAnd age? (Age first performed activity 
5c.2.3aANGTOILETTIMEDABILITYLTimed to go to the toilet (eg taken to the toilet every 3 hours)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.3bANGTOILETTIMEDABILITYDKOr, don’t know 
5c.2.3cANGTOILETTIMEDFREQLAnd frequency 
5c.2.3dANGTOILETTIMEDAGELAnd age? (Age first performed activity 
5c.2.4aANGTOILETINDICATEABILITYLIndicates when they want to go to the toilet1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.4bANGTOILETINDICATEABILITYDKOr, don’t know 
5c.2.4cANGTOILETINDICATEFREQLAnd frequency 
5c.2.4dANGTOILETINDICATEAGELAnd age? (Age first performed activity 
5c.2.5aANGTOILETSTOOLSABILITYLContinent of stools (bowel movements)1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.5bANGTOILETSTOOLSABILITYDKOr, don’t know 
5c.2.5cANGTOILETSTOOLSFREQLAnd frequency 
5c.2.5dANGTOILETSTOOLSAGELAnd age? (Age first performed activity 
5c.2.6aANGTOILETURINEDAYABILITYLContinent of urine (dry) during the day1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.6bANGTOILETURINEDAYABILITYDKOr, don’t know 
5c.2.6cANGTOILETURINEDAYFREQLAnd frequency 
5c.2.6dANGTOILETURINEDAYAGELAnd age? (Age first performed activity 
5c.2.7aANGTOILETURINENIGHTABILITYLContinent of urine (dry) at night1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown 
5c.2.7bANGTOILETURINENIGHTABILITYDKOr, don’t know 
5c.2.7cANGTOILETURINENIGHTFREQLAnd frequency 
5c.2.7dANGTOILETURINENIGHTAGELAnd age? (Age first performed activity 

 

5c. 3. Adaptive Behaviour: Eating – please describe your child/adult’s ability to do the following: (ANGBEHDEVEATING2L)
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5c.3.1aANGBEHDEVDONTLIKEAre there textures or tastes he/she really doesn’t like?1 – Yes;
2 – No;
3 – Unknown
5c.3.1bANGBEHDEVDONTLIKEWHAT2Please give examples.1 – Meat or fish;
2 – Fruit or vegetables
3 – Rice, pasta or bread
4 – Beans;
5 – Thick textures or pastes;
6 – Crunchy textures;
7 – Eggs;
8 – Hard textures;
9 – Soft textures;
10 – Crispy textures;
11 – Hot foods;
12 – Cold foods;
13 – Salty or savory foods;
14 – Sweet foods;
15 – Sour foods;
16 – Spicy foods;
17 – Dry textures;
18 – Wet textures;
19 – Solid foods;
20 – Chewy textures;
21 – Other
5c.31cANGBEHDEVDONTLIKEWHATIf yes, please give examples 
5c.3.2aANGEATINGFUSSYFREQLFussy with their food –  frequency 
5c.3.2bANGEATINGFUSSYAGELAnd age? (Age first performed activity 
5c.3.3aANGFINEMOTORBOTTLEABILITYLHold a bottle1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.3bANGFINEMOTORBOTTLEABILITYDKOr, don’t know 
5c.3.3cANGFINEMOTORBOTTLEFREQLAnd frequency 
5c.3.3dANGFINEMOTORBOTTLEAGELAnd age? (Age first performed activity 
5c.3.4aANGEATINGTEXTUREABILITYLChew all textures1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.4bANGEATINGTEXTUREABILITYDKOr, don’t know 
5c.3.4cANGEATINGTEXTUREAGELAnd age? (Age first performed activity 
5c.3.5aANGFINEMOTORFEEDABILITYLFinger feed1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.5bANGFINEMOTORFEEDABILITYDKOr, don’t know 
5c.3.5cANGFINEMOTORFEEDFREQLAnd frequency 
5c.3.5dANGFINEMOTORFEEDAGELAnd age? (Age first performed activity 
5c.3.6aANGFINEMOTORSPOONABILITYLHold a spoon and feed1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.6bANGFINEMOTORSPOONABILITYDKOr, don’t know 
5c.3.6cANGFINEMOTORSPOONFREQLAnd frequency 
5c.3.6dANGFINEMOTORSPOONAGELAnd age? (Age first performed activity 
5c.3.7aANGFINEMOTORFORKABILITYLUse a fork1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.7bANGFINEMOTORFORKABILITYDKOr, don’t know 
5c.3.7cANGFINEMOTORFORKFREQLAnd frequency 
5c.3.7dANGFINEMOTORFORKAGELAnd age? (Age first performed activity 
5c.3.8aANGEATINGFEEDSELFABILITYLFeed self using fingers or utensils1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.8bANGEATINGFEEDSELFABILITYDKOr, don’t know 
5c.3.8cANGEATINGFEEDSELFFREQLAnd frequency 
5c.3.8dANGEATINGFEEDSELFAGELAnd age? (Age first performed activity 
5c.3.9aANGFINEMOTORHOLDCUPABILTYLHold a cup or tumbler and drink1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.9bANGFINEMOTORHOLDCUPABILTYDKOr, don’t know 
5c.3.9cANGFINEMOTORHOLDCUPFREQLAnd frequency 
5c.3.9dANGFINEMOTORHOLDCUPAGELAnd age? (Age first performed activity 
5c.3.10aANGEATINGFEEDSUPPORTFREQLNeed support with feeding from a parent/caregiver – frequency1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.10bANGEATINGFEEDSUPPORTAGELAnd age? (Age first performed activity 
5c.3.11aANGEATINGFULLABILITYLIndicates that they are full1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.11bANGEATINGFULLABILITYDKOr, don’t know 
5c.3.11cANGEATINGFULLFREQLAnd frequency 
5c.3.11dANGEATINGFULLAGELAnd age? (Age first performed activity 
5c.3.12aANGEATINGSUPPLEMENTFREQLUse supplementation in the form of additional formulas – frequency1 – No difficulty;
2 – Mild difficulty;
3 – Moderate difficulty;
4 – Severe difficulty;
5 – Unable to perform activity;
6 – Unknown
5c.3.12bANGEATINGSUPPLEMENTAGELAnd age? 

 

5c.4 Other comments (ANGADAPTCOMMENTSec)
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5c.4.1ANGADAPTCOMMENTAny other comments about your child/ adult’s dressing, toileting or eating? 

 

5d.1 Activities (ANGBEHDEVACTIVITIES)
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5d.1.1aANGBEHDEVPREFACTWhat are your child/ adult’s preferred activities? (Check all that apply)1 – Socialising
2 – Being with familiar people
3 – Playing social games such as peek a boo or hide and seek
4 – Watching TV
5 – Using technology and games, e.g. iPads
6 – Swimming
– Being outside;
8 – Music or dancing;
9 – Playing with toys;
10 – Riding a bike or scooter;
11 – Riding in a car/ travelling;
12 – Eating/ mealtimes;
13 – Bathing;
14 – Playing on play equipment;
15 – Other
51.1bANGBEHDEVACTOTHIf other, Please state 

 

5d.2 Behavioural (ANGBEHDEVBEHAVIOURAL)
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5d.2.1ANGBEHDEVGOODBEH2How problematic do you see your child/ adult’s behaviour on a scale of 1 to 10 in comparison to age matched typical peers?Scale 1-10 (1 – No problems to 10 – Major problems) 

 

5d.3 Do they exhibit any of the following behaviours? l (ANGBEHDEVBEHAVIOURAL2)
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5d.3.1aANGBEHDEVREPETLRepetitive behaviours such as slapping the wall 
5d.3.1bANGBEHDEVREPETDKOr, don’t know 
5d.3.2aANGBEHDEVFOCALLUnusual movements that are repetitive: Focal hand movements 
5d.3.2bANGBEHDEVFOCALDKOr, don’t know 
5d.3.3aANGBEHDEVWHOLEBODYLWhole body movements 
5d.3.3bANGBEHDEVWHOLEBODYDKOr, don’t know 
5d.3.4aANGBEHDEVMOUTHLMouthing or chewing 
5d.3.4bANGBEHDEVMOUTHDKOr, don’t know 
5d.3.5aANGBEHDEVAGITATIONNEWLDo they exhibit any of the following behaviours? Agitation in new situations 
5d.3.5bANGBEHDEVAGITATIONNEWDKOr, don’t know 
5d.3.6aANGBEHDEVFEARSTRANGERLFear of strangers 
5d.3.6bANGBEHDEVFEARSTRANGERDKOr, don’t know 
5d.3.7aANGBEHDEVSOCIALLWill socialise with anyone 
5d.3.7bANGBEHDEVSOCIALDKOr, don’t know 
5d.3.8aANGBEHDEVFEARNEWLFear of new situations 
5d.3.8bANGBEHDEVFEARNEWDKOr, don’t know 
5d.3.9aANGBEHDEVANXIOUSLAnxious behaviours 
5d.3.9bANGBEHDEVANXIOUSDKOr, don’t know 
5d.3.9cANGBEHDEVANXIOUSWHENWhen do they show these behaviours1 – New situations or people;
2 – Overstimulating settings (e.g. loud noise or crowds) ;
3 – Separation from parent/ caregiver ;
4 – Medical settings or tests;
5 – Having to wait;
6 – When ill or injured;
7 – When hungry or thirsty ;
8 – When unable to communicate;
9 – Other (Range/ DefaultWidget; AnxiousBeh)
5d.3.9dANGBEHDEVANXIOUSWHAT2What anxious behaviours1 – Crying;
2 – Repetitive movements or laughter;
3 – Aggression (e.g. hitting, grabbing or hair pulling);
4 – Self harm (e.g biting own hand);
5 – Yelling or other vocalisations;
6 – Gagging or vomiting;
7 – Clinging to caregiver;
8 – Mouthing or chewing objects;
9 – Avoidance (e.g. drop to floor); 1
0 – Escape (e.g. running away);
11 – Other 
5.56.11ANGBEHDEVANXIOUSWHATIf yes to anxious behaviours, what? 
5d.3.10aANGBEHDEVOPPOSITIONALLOppositional behaviours, e.g. refusing to do something 
5d.3.10bANGBEHDEVOPPOSITIONALDKOr, don’t know 
5d.3.11aANGBEHDEVBITINGLAggressive behaviours: biting 
5d.3.11bANGBEHDEVBITINGDKOr, don’t know 
5d.3.12aANGBEHDEVHAIRPULLINGLHair pulling 
5d.3.12bANGBEHDEVHAIRPULLINGDKOr, don’t know 
5d.3.13aANGBEHDEVHITTINGLHitting 
5d.3.13bANGBEHDEVHITTINGDKOr, don’t know 
5d.3.14aANGBEHDEVGRABBINGLGrabbing 
5d.3.14bANGBEHDEVGRABBINGDKOr, don’t know 
5d.3.15aANGBEHDEVHYPERACTIVITYLHyperactivity 
5d.3.15bANGBEHDEVHYPERACTIVITYDKOr, don’t know 
5d.3.16aANGBEHDEVPOORATTENTIONLPoor attention 
5d.3.16bANGBEHDEVPOORATTENTIONDKOr, don’t know 
5d.3.17aANGBEHDEVGOODCONCENTRATIONLGood concentration on things he/she enjoys such as iPad games 
5d.3.17bANGBEHDEVGOODCONCENTRATIONDKOr, don’t know 
5d.3.18aANGBEHDEVWATERLFascination with water 
5d.3.18bANGBEHDEVWATERDKOr, don’t know 
5d.3.19aANGBEHDEVIMPULSIVITYLImpulsivity – such as running out on road/hitting out 
5d.3.19bANGBEHDEVIMPULSIVITYDKOr, don’t know 
5d.3.20aANGBEHDEVSMILINGNOTHINGLFrequent smiling at nothing in particular 
5d.3.20bANGBEHDEVSMILINGNOTHINGDKOr, don’t know 
5d.3.21aANGBEHDEVSMILINGLFrequent appropriate smiling 
5d.3.21bANGBEHDEVSMILINGDKOr, don’t know 
5d.3.22aANGBEHDEVSPONTLAUGHTERLSpontaneous laughter at nothing in particular 
5d.3.22bANGBEHDEVSPONTLAUGHTERDKOr, don’t know 
5d.3.23aANGBEHDEVNIGHTLAUGHTERLNight time laughter 
5d.3.23bANGBEHDEVNIGHTLAUGHTERDKOr, don’t know 
5d.3.24aANGBEHDEVAPPROPRIATELAUGHTERLAppropriate laughter 
5d.3.24bANGBEHDEVAPPROPRIATELAUGHTERDKOr, don’t know 
5d.3.25aANGBEHDEVSEPANXIETYLSeparation anxiety 
5d.3.25bANGBEHDEVSEPANXIETYDKOr, don’t know 
5d.3.26aANGBEHDEVFEARLEFTLFear of being left at school or in care situations 
5d.3.26bANGBEHDEVFEARLEFTDKOr, don’t know 
5d.3.27aANGBEHDEVSKINPICKINGLDo they exhibit self harming behaviour: Skin picking 
5d.3.27bANGBEHDEVSKINPICKINGDKOr, don’t know 
5d.3.28aANGBEHDEVHEADBANGINGLHead banging 
5d.3.28bANGBEHDEVHEADBANGINGDKOr, don’t know 
5d.3.29aANGBEHDEVSELFHITTINGLSelf hitting 
5d.3.29bANGBEHDEVSELFHITTINGDKOr, don’t know 

 

5d.4 Other comments (ANGBEHAVCOMMENTSec)
NoCodeQuestionResponse
5d.4.1ANGBEHAVCOMMENTAny other comments about your child/ adult’s behaviour? 

 

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