History form - ASD

Asks about developmental symptoms and history - please answer in as much detail as possible with examples where available. It is often useful to complete it with an informant such as a parent or family member
  • Was it your idea or someone else's to seek this assessment?
  • eg do you have parents, siblings, spouse/partner, children, grandparents etc.?
  • If you don't get along with any family members, why do you think this is?
  • eg. text, face to face contact, talk on phone etc.
  • EARLY LIFE
  • You may not know the answer to these questions, please just provide the information you or informant have
  • eg settled baby, cried a lot, didn't sleep, often sick etc.
  • Please enter a number from 1 to 48.
  • Please enter a number from 1 to 10.
  • Please enter a number from 4 to 48.
  • Please enter a number from 1 to 100.
  • Please enter a number from 0 to 100.
    Put zero if still not able to do it
  • Please enter a number from 0 to 100.
    Put zero if still unable to do this
  • Please enter a number from 0 to 100.
    Put zero if still unable to do this
  • Please enter a number from 0 to 100.
    Put zero if still unable to do it
  • Please enter a number from 0 to 100.
    Put zero if still unable to do this
  • If yes, was this with any specific people?
  • EDUCATION
  • School Years Please write below, what nursery, pre-school, infant, primary and secondary schools you went to and at what age:
  • Did you enjoy nursery? Why, or why not? Do you know what teacher’s feedback said about you? if so, what was it?
  • Did you enjoy pre-school? Why, or why not? Do you know what teache’sr feedback was about you? if so, what was it?
  • Do you know what teache’sr feedback was about you? if so, what was it?
  • Do you know what teachers' feedback was about you? if so, what was it?
  • If yes, what did you do? e.g., birthday parties, sleepovers, did you enjoy them?
  • e.g., sports clubs, girl guides/boy scouts etc, did you enjoy these?
  • EMPLOYMENT HISTORY
  • If you have ever worked can you list the jobs you have done, and the years you worked at these jobs below: For each job please list job role, employer and dates worked there, problems encountered and reasons for leaving
  • e.g., did you form friendships, socialise out of work? Have you ever been bullied in the workplace?
  • COMMUNICATION
  • e.g. body language, gesture, facial expression, group dynamics etc If you struggle with any, which ones are more difficult for you?
  • Do you have black and white thinking? Do you think literally?
  • ROUTINES, RIGIDITY AND FOCAL/REPETITIVE INTERESTS/SENSITIVITIES
  • e.g., if your plans change unexpectantly. If so, can you give some examples and how it affects you?
  • e.g., buy same brands, eat same foods, repeated body movements, intense interests etc.
  • PRESENT SOCIAL CIRCUMSTANCES
  • PSYCHIATRIC AND MEDICAL HISTORY
  • ACTIVITIES OF DAILY LIFE