Autism Intake Page 2

Please correct the errors described below.

YOUR CHILD'S NAME:

DATE:

DATE QUESTIONNAIRE COMPLETED:

IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE DESCRIBE BELOW:

WE WOULD LIKE TO KNOW HOW YOU ARE DOING:

How many hours of uninterrupted sleep do you usually get each night?

Does your child sleep with you?

Yes No

Most days do you feel:

tired rested exhausted full of energy

Do you have a physician for yourself?

Yes No

Do you have any current medical problems?

Yes No

If YES, please describe:

Do you take prescription medication for any reason?

Yes No

Do you currently take a daily multi-vitamin?

Yes No

Do you eat regular meals?

Yes No

You engage in physical exercise or a relaxation activity:

daily 1-2 times per wk hardly ever not at all

On most days your mood is:

good fair not so good

How do you cope with stress?

pretty good fair not so good

Are there days when you feel overwhelmed?

Yes No

Do you have anyone you can depend on to help you with your child?

Yes No

Are you confident in your child’s physician?

Yes No

Do you feel you can be honest and openly discuss your concerns about your child with his/her physician?

Yes No

Do you attend any support groups?

Yes No

Do you feel your psychological needs are met?

Yes No

If you would like to add anything, please do so in the space below:

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. WE HOPE THAT THE INFORMATION YOU HAVE PROVIDED WILL HELP US TO BETTER UNDERSTAND YOUR CHILD AND PROVIDE YOUR FAMILY WITH THE BEST CARE.

THE UNIVERSITY OF FLORIDA AUTISM TEAM

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