Child ASD History form

Asks about developmental symptoms and history - please answer in as much detail as possible with examples where available. It is usually best completed by an informant such as a parent or family member

• Child's name*
  First
• Informant's name*
• Informant's relationship to the child*
• Informant's email address*
• Biological mother's occupation*
• Biological father's occupation*
• Number of full/ half siblings and the child's place*
• Any blood relatives showing similar symptoms?*
• Please tell us what you are particularly concerned about, with as much detail as possible. How long has this been a problem?*
  Was it your idea or someone else's to seek this assessment?
• EARLY LIFE
• What was the mother's pregnancy like? Any difficulties or issues? Was the child's birth at, before or after expected date?*
• Was the child born by full term normal delivery and well after birth? Any early risk factors in the child's history*
• Was the child active as a baby and young child? Any other early characteristics?*
• Any delay in starting sitting up / walking / talking (early milestones) ?*
• Is the child clumsy? Please give details*
• What age did the child first babble (in months)?*
  Please enter a number from 1 to 48.
• What age did the child first talk (in years)?*
  Please enter a number from 1 to 10.
• What age did the child first walk (in months)?*
  Please enter a number from 4 to 48.
• What age did the child no longer need nappies (in years)?*
  Please enter a number from 1 to 100.
• What age did the child first tie their shoelaces (in years)?*
  Please enter a number from 0 to 100.
  Put zero if still not able to do it
• What age did the child first fasten and undo buttons (in years)?*
  Please enter a number from 0 to 100.
  Put zero if still unable to do this
• What age was the child first able to use zips (in years)?*
  Please enter a number from 0 to 100.
  Put zero if still unable to do this
• What age did the child first ride a bicycle (in years)?*
  Please enter a number from 0 to 100.
  Put zero if still unable to do it
• What age could the child first throw and catch balls (in years)?*
  Please enter a number from 0 to 100.
  Put zero if still unable to do this
• Did the child like cuddles?*
  If yes, was this with any specific people?
• If the child has siblings, did the child like to play with them, or did they prefer to play alone?*
• If the child did play with siblings, what types of games/play did they do?*
• What were the child's favourite toys?*
• Did the child ever collect toys/memorabilia? If so, what were they and does the child still have them?*
• Did the child go on holidays with family? Did the child enjoy them?*
• Did the child attend family parties/gatherings? Did the child enjoy them?*
• Did the child have any significant illness, accident or specific needs that required intervention from professionals in early childhood?*
• EDUCATION
• School Years*
  School Years Please write below, what nursery, pre-school, infant, primary and secondary schools the child went to and at what age:
• Did the child need to change schools at any time? If so, what were the reasons for this?*
• Did the child ever get issued with a statement of educational need at school? If so, what was this for?*
• Did the child receive any additional support in school to help them to engage in lessons or learn? If so, what was this support, and did it help?*
• Did the child enjoy nursery? Why, or why not?*
  Did you enjoy nursery? Why, or why not? Do you know what teacher’s feedback said about you? if so, what was it?
• Did the child enjoy pre-school? Why, or why not?*
• Difficulties in primary school*
  Struggled to listen/zoned outFidgetyNaughty/in trouble a lotProblems with authority/rulesDifficulty with readingDifficulty with spellingDifficulty with handwritingProblems with maths/numbersStruggled with friendshipBullied
• Did the child enjoy primary school (infants)? Why, or why not?*
• Academic level at end of primary school (aged 11) ?*
• Describe the child's secondary school experience up to GCSE. How was it similar or different from primary school?*
• How well did the child cope with the transitions between schools?*
• What subjects does the child enjoy at school?*
• Prior to GCSE did the child?*
  • Struggled to revise• Homework not done/done last minute• Achieved potential
  Just put x if below GCSE age
• How many GCSEs did the child get with approximate grades?*
  Just put x if pre GCSE
• Describe the child's sixth form school or college experience. What exams did they get with grades if remembered? Did you achieve your potential?*
• Did the child make friends at school? If so, who were their friends at school? Does the child see any friends out of school?*
  If yes, what did the chilu do? e.g., birthday parties, sleepovers, did they enjoy them?
• Does the child still see any old school friends?*
• Did the child go to any clubs or do out of school activities?*
  e.g., sports clubs, girl guides/boy scouts etc, did the child enjoy these?
• If the child attended did they get on with other students when doing further education? Did the child make any friends, if so, who were they?*
• COMMUNICATION
• Communication: Do people ever misinterpret what the child says and means? If so, in what way?*
• Does the child ever misinterpret what people say to them or what they intend? If so, in what way?*
• Does the child ever find it difficult to be in social situations with people they know, or don’t know? If so why and what helps the child cope in these situations?*
• Can the child easily understand non-verbal communication?*
  e.g. body language, gesture, facial expression, group dynamics etc If the child struggles with any, which ones are more difficult for them?
• Does the child understand humour, banter, sarcasm, metaphors or euphemism? If they struggle with any, which ones do they find more difficult to understand?*
• Is the child able to imagine how other people may be feeling? If not, in what way do they struggle with this?*
• Can the child feel empathy? And are they able to show empathy? How does the child express it?*
• Can the child initiate conversations? Can they maintain conversations with people even if the topic does not interest them? If not, what does the child struggle with?*
• Is the child able to routinely look people in the eyes when they talk to them? Does the child routinely use gestures and change the tone of their voice to enhance what they are saying to someone? If the child struggles with any of these, which ones and what do they find difficult.*
• Do people describe the child as an opinionated person?*
  Does the child have black and white thinking? Do they think literally?
• ROUTINES, RIGIDITY AND FOCAL/REPETITIVE INTERESTS/SENSITIVITIES
• Does the child currently have any routines? If so, what are these? e.g., things that they like to do at a set time or in a set way?*
• Does the child have difficulties coping with change?*
  e.g., if plans change unexpectantly. If so, can you give some examples and how it affects the child?
• How does the child spend their time at home? Are you satisfied with how they spend their time?*
• Does the child like having any order to their belongings? If so, can you provide examples?*
• If the child has to do something new or go somewhere new, how do they prepare themselves?*
• What are the child interests? How much time each week do they engage in these interests?*
• Does the child do anything repetitively and if so what?*
  e.g., buy same brands, eat same foods, repeated body movements, intense interests etc.
• Does the child have any sensitivity to light, sound, taste, smell, touch? If so which ones and in what way?*
• PRESENT SOCIAL CIRCUMSTANCES
• How does the child get along with their family? Who is closest to them?*
  If the child doesn't get along with any family members, why do you think this is?
• In relationships and friendships, does the child struggle with?*
  • Shyness• Boredom• Jealousy• Oversensitivity and / or overthinking• Feeling suffocated or overwhelmed by others
• Does the child have any friends? If so, who are they, how long have they known them and how often do they have contact with them?*
• Is the child currently in a romantic relationship? Please describe their relationship history*
• Is the child involved in any clubs, groups or other organised e.g. cultural or spiritual activities? If so, what are these and how many hours each week do they participate in them?*
• PSYCHIATRIC AND MEDICAL HISTORY
• Are you currently in education? If so, what are you doing? How many hours is this each week?*
• Does the child have any health conditions (physical or mental)? If so, what are these?*
• Is the child currently receiving any treatment for a condition? If so, what? e.g. medication, counselling, talking therapy*
• Is the child receiving input from any specialist agencies/health professionals? If so, who?*
• Has the child struggled much with low mood? Ever taken antidepressants or other mental health medications?*
• What about anxiety? What makes the child anxious? Is the child a very anxious person? Ever had a panic attack?*
• Briefly summarise any therapy/ counselling the child has had and when. Did it help at all and if so, how?*
• Has the child ever been in trouble with the law?*
• Any sleeping issues, past or present. Does the child use any specific strategies to help with sleep?*
• Please describe any eating disorders or problems past or present?*
• Does the child have any issues with alcohol or drugs past or present. How much alcohol/ drugs do they use currently, and how often?*
• Does the child drive currently?*
• Was the child slower/ worse than others with learning to tie shoelaces, ride a bike etc.?*
• Is the child clumsy?*
• Does the child have problems with distinguishing left and right or finding their way around?*
• ACTIVITIES OF DAILY LIFE
• Is tthe child able to cook? Independently or with support?*
• Is the child able to shop for food? Independently or with support?*
• Is the child able to shop for clothes? Independently or with support?*
• Is the child able to help with household chores? Independently or with support?*
• Is the child able to manage their laundry? Independently or with support?*
• Is the child able to make appointments? Independently or with support?*
• Is the child able to attend appointments? Independently or with support?*
• Is the child able to use public transport? Independently or with support?*
• Is the child able to manage money? Independently or with support?*
• Is the child able to use a phone? Independently or with support?*
• Is the child able to drive? Independently or with support?*
• Is the child able to ask for help? Independently or with support?*
• Is there anything else that would be helpful for us to know?

Child ASD History form