Questions for parents with a child with suspected autism

Step 1 of 11

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Date of Completion(Required)

GP's Name(Required)

First Last

GP's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

GP's Phone(Required)

GP's Email(Required)

Parent/Guardian Name(Required)

Title First Last Marital Status

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Mobile(Required)

Email(Required)

Permanent Address - Is this the same address as the patient's?(Required)

Yes

Do you have parental responsibility?(Required)

Yes

Parent/Guardian Name(Required)

Title First Last Marital Status

If 'No' please specify address below

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone(Required)

Mobile(Required)

Email(Required)

Permanent Address - Is this the same address as the patient's?(Required)

Yes

Do you have parental responsibility?(Required)

Yes

Additional Carer Name (any other biological/foster/adoptive parents)

Title First Last

Relationship to Child

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Other Professional Support

Profession First Name Last Name

Does your child receive support from any other profession, such as paediatric or psychiatric care? Are you receiving any services such as speech and language therapy or occupational therapy? Do you attend any behavioural management programmes?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Other Professional Support

Profession First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

What was the lebgth of the pregnancy (in weeks)?(Required)

Did you smoke at all during pregnancy?(Required)

Yes, 0-3 months

Yes, 4-6months

Yes, 7-9 months

Did you drink alcohol at all during pregnancy?(Required)

Yes, 0-3 months

Yes, 4-6months

Yes, 7-9 months

Did anything abnormal or worrying occur during the pregnancy?(Required)

Yes

If yes, what were the difficulties?

Was your child born in hospital?(Required)

Yes

If no what were the birth arrangements?

Were there any difficulties during the birth?(Required)

Yes

If yes what were the difficulties?

What was your child's birth weight (kg)?(Required)

For how many days after the birth were you in hospital?(Required)

For how many days was your baby in hospital after birth?(Required)

Was your baby in a Special Care Baby Unit (SCBU)?(Required)

Yes

Has your child ever had a hospital outpatient appointment?(Required)

Yes

If yes, please specify hospital name

Name

How old was your child?

Reason for appointment

Treatment

If more than one outpatient appointment please give details below

Has your child ever been admitted to hospital?(Required)

Yes

If yes, please specify hospital name

Name

How old was your child?

Reason for appointment

Treatment

If more than one outpatient appointment please give details below

Has your child ever had to go to a casualty or emergency department?(Required)

Yes

If yes, please specify hospital name

Name

How old was your child?

Reason for appointment

Treatment

If more than one outpatient appointment please give details below

Has your child ever had a fit or convulsion?(Required)

Yes

If yes, please give details

Has your child ever had an ear infection?(Required)

Yes

If yes, how old was he/she when this occurred? (Years & Months)

If yes, please provide details

Has your child ever suffered from glue ear?(Required)

Yes

If yes, how old was he/she when this occurred? (Years & Months)

If yes, please provide details

Has your child ever had grommets put in?(Required)

Yes

If yes, how old was he/she when this occurred? (Years & Months)

If yes, please provide details

Does your child need to have the TV turned up louder than usual?(Required)

Yes

Does your child struggle to hear in a one-to-one conversation?(Required)

Yes

Has your child ever suffered hearing loss in either or both ears?(Required)

Yes

Have you ever thought your child might be deaf?(Required)

Yes

Has your child ever had a medical assessment (audiometry) for hearing problems?(Required)

Yes

Please list below, in date order, playgroups/preschool/schools attended. Please specify name of group/school, stage, age started, age left, details of any difficulties, details of any help given(Required)

Current School Name

Name

Current School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Headteacher's Name

First Last

Do you feel your child has special educational needs?(Required)

Yes

If yes, please give brief details of needs

Does your child have any extra help at school?(Required)

Yes

If yes, in which areas? (for example: reading, spelling, maths, communication problems)

Is your child expected to do homework?(Required)

Yes

Does your child make careless mistakes when doing their homework?

Possibly

Definitely

Is your child much worse in making careless mistakes than other children their age?

Possibly

Definitely

Is the child on the Special Educational Needs code of practice?(Required)

Yes

If yes, what is the child’s level on the code of practice?

School action

School action plus

Statement of special needs issued

Has your child ever belonged to any school clubs or other clubs (Cubs, Sports club, Youth club etc)?(Required)

Yes

If yes, please give details

Has your child ever been asked to leave a club for any reason?(Required)

Yes

If yes, please give details of why they were asked to leave

How was your child fed at the very beginning?(Required)

Breast

Bottle

While still on fluids (bottle or breast), were there any difficulties?(Required)

Yes

If yes, please give details:

At what age was your child introduced to solids? (Years and months)(Required)

What solids was your child started on?

Did he/she have any of these difficulties when starting with solids?(Required)

If yes, please give details (e.g. difficulties with chewing, gagging, persistent dribbling, problems with mixed textures e.g. fruit yogurt)

Does your child have current problems with food that needs chewing (such as meat)?(Required)

Yes

If yes, please give details (e.g. food has to be cut up, eats without chewing etc)

Does your child avoid food that contain a mixture of textures (such as fruit yoghurt, or orange juice with floating bits in)?(Required)

Yes

If yes, please give details (e.g. avoids such foods, avoids orange juice with bits in etc)

Does your child eat very quickly?(Required)

Yes

If yes, please give details (e.g. fills mouth completely before swallowing etc)

Or does your child eat very slowly?(Required)

Yes

If yes, please give details (e.g. last to finish etc)

Does your child’s appetite vary considerably from day to day?(Required)

Yes

If yes, please give details

Does your child drink a lot, more than other children of his/her age?(Required)

Yes

If yes, please give details

Does your child sweat a lot at night?(Required)

Yes

If yes, please give details of sweating and whether anyone in family sweats similarly

Did your child ever have problems sleeping as a baby?(Required)

Yes

If yes, please give details

At what time is your child asked to go to bed?(Required)

At what time will your child actually go to bed?(Required)

At what time will your child actually go to sleep?(Required)

At what time does your child usually wake up in the morning?(Required)

Does your child complain of waking up and not being able to get back to sleep?(Required)

Never

Sometimes

Often

Does your child wake up at night (not sleepwalking) and wander round the house?(Required)

Never

Sometimes

Often

Where does your child usually sleep at night? Please tick one of the following(Required)

Own bed (own room)

Own bed (parents’ room)

Own bed (Siblings or others room)

In parents’ bed

In bed with others

Does your child ever refuse to go to sleep without someone staying near by?(Required)

Definitely

Possibly

Does your child ever come into your room in the middle of the night?(Required)

Definitely

Possibly

Has your child ever refused to spend a night away from you?(Required)

Yes

Does your child have nightmares?(Required)

Yes

Are these nightmares ever about being taken away from you or your leaving?

Yes

Possibly

Does your child have night terrors (waking screaming/frightened, but with no recollection in the morning)?(Required)

Yes

Possibly

Does your child sleepwalk?(Required)

Yes

Have you ever approached your GP, health visitor or someone else for help with a sleeping problem your child has had?(Required)

Yes

Does your child have diarrhoea?(Required)

Often

Sometimes

Never

Does your child have constipation?(Required)

Often

Sometimes

Never

How old was your child when he/she first sat without support on a firm surface? (Years and months)(Required)

How did your child begin to move around? Please tick one(Required)

Don’t know or cannot remember

Crawling on hands and knees

Crawling commando style

Shuffling on bottom

Rolling

At what age did this happen? (Years and months)(Required)

At what age did your child walk without holding on? (Years and months)(Required)

Is there anything unusual about the way your child walks now? (e.g. bouncing, exaggeration of toe-heel, up on toes)(Required)

First Choice

Second Choice

Third Choice

If yes please give details

Can your child ride a bicycle?(Required)

Has no problem

Adequately

With Difficulty

Can your child kick a ball that isn't moving?(Required)

Has no problem

Adequately

With Difficulty

Can your child kick a ball while moving her/his self?(Required)

Has no problem

Adequately

With Difficulty

Can your child negotiate an object that is in the way but below their line of vision such as a low table? (e.g. would he/she manage not to walk into it?)(Required)

Has no problem

Adequately

With Difficulty

Can your child dance to music and how does that work out from the point of view of coordination and so on?(Required)

Has no problem

Adequately

With Difficulty

Can your child use a pencil or pen to produce reasonably neat writing?(Required)

Has no problem

Adequately

With Difficulty

Can your child use a crayon or pencil for drawing purposes?(Required)

Has no problem

Adequately

With Difficulty

Can your child use a pair of scissors (without supervision)?(Required)

Has no problem

Adequately

With Difficulty

Can your child use a knife and fork?(Required)

Has no problem

Adequately

With Difficulty

Can your child hold a piece of meat with the fork and cut it with the knife?(Required)

Has no problem

Adequately

With Difficulty

If yes, when was your child first able to do this? (Years and months)

How do your child’s knife and fork skills compare with those of siblings when they were his/her age?(Required)

Same

Better

Not as good

Comparison not appropriate

Can your child tie their shoelaces without help?(Required)

Has no problem

Adequately

With Difficulty

Can your child use their hands to make things or fit things together such as Lego?(Required)

Has no problem

Adequately

With Difficulty

Can your child turn a key the right way to get through a door?(Required)

Has no problem

Adequately

With Difficulty

Can your child get dressed the right way (e.g. not putting things on the wrong way round or putting both legs in one trouser leg)?(Required)

Has no problem

Adequately

With Difficulty

Can your child coordinate filling a glass from a jug?(Required)

Has no problem

Adequately

With Difficulty

Can your child turn a doorknob the right way to get through a door?(Required)

Has no problem

Adequately

With Difficulty

Which hand does your child prefer to use when completing tasks?(Required)

Left

Right

Mixed

Which is the dominant hand for father?(Required)

Left

Right

Mixed

Which is the dominant hand for mother?(Required)

Left

Right

Mixed

Is your child sensitive NOW to every day noises such as a crowded street or a vacuum cleaner?(Required)

Yes

If yes, at what age did this begin? (Years and months)

If no, was your child EVER sensitive to such every day noises?

Yes

At what age did this begin? (Years and months)

Does your child sometimes NOW put his/her hands over his/her ears in response to ordinary sounds?(Required)

Yes

At what age did this begin? (Years and months)

If no, did your child EVER put his/her hands over his/her ears in response to ordinary sounds?

Yes

At what age did this begin? (Years and months)

Does your child sometimes complain NOW that music is too loud?(Required)

Yes

At what age did this begin? (Years and months)

If no, did your child EVER complain that music was too loud?

Yes

At what age did this begin? (Years and months)

Have you ever had to adjust what you do because he/she is upset by noises?(Required)

Yes

If yes, please give details