Child and Adolescent-Autism Intake

AMS Psychiatry

Please correct the errors described below.

Add Another Phone Number

Information about the Child and Family

Mother completed:

Father completed:

Other children in the family:

Add Another Child

Please list your child’s previous psychiatric treatment below:

Inpatient:

Add New Inpatient Entry

Outpatient:

Add New Outpatient Entry

Please tell us about the medications and/or supplements that have been tried with your child in the past by completing the table below.

If you answer yes to each current medication, please provide the "Dose/Include Maximum Dose Tried", "Date/Length of Trial", and "RESULTS/Reason for stopping (side effects)". Otherwise, please leave these empty.

STIMULANTS:

ANTIDEPRESSSANTS:

NEUROLEPTICS:

ANTICONVULSANTS/MOOD STABILIZERS:

SUPPLEMENTS:

Please tell us about your child’s previous evaluations by completing the table below:

Testing:

Please describe your child’s medical history:

Has your child ever had any problems in the following areas (please describe):

PLEASE TELL US ABOUT YOUR CHILD’S DEVELOPMENT

PREGNANCY

BIRTH:

POSTNATAL:

DEVELOPMENTAL MILESTONES

What age was your child when he/she:

Sat alone:

TOILET TRAINING: Dry days

TOILET TRAINING: Dry nights

TOILET TRAINING: No accidents

Crawled:

Walked:

Rode a tricycle:

Drank from a cup w/o spilling:

Used a spoon:

Talked (single word):

Talked in phrases:

Talked in sentences:

Echolalia (repeating words or sentences)

Undressed without help:

Dressed without help

Brushed hair without help

Bathed without help

Tied shoelaces

Brushed teeth without help

Please tell us about your family’s history by checking all that apply below:

Please tell us about your child’s school history:

WE WOULD LIKE TO KNOW HOW YOU ARE DOING:

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.

Your information will be encrypted.

Loading...