Child and Adolescent-Autism Intake

AMS Psychiatry

Please correct the errors described below.

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Information about the Child and Family

Mother completed:

Father completed:

Other children in the family:

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Please list your child’s previous psychiatric treatment below:

Inpatient:

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Outpatient:

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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.

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