Identifying Information and Healthcare Provider (For Child Patient)

Client Intake
The following questionnaire is to be completed by the individual’s parent or

legal guardian. Please complete this form to the best of your ability. We recognize
that you may not have the answers to all questions. All information requested in
this form is important and will allow us to provide you with the most accurate
diagnosis and optimal treatment and care plans. Thank you for taking the time to
complete it
Identifying Information and Healthcare Provider (for Child Patient)
1. Patient’s Name: 2. Patient’s Date of Birth:
3. Name of Person completing form:

Please indicate your relationship to the patient:
☐ Parent (☐ Biological ☐ Adoptive ☐ Foster) ☐ Guardian ☐ Other, specify:
4. Please answer the following questions about the patient’s living situation:
If the patient is a minor:

Are the child’s parents Divorced/Separated? ☐ No ☐ Yes
If Divorced/Separated, who is responsible for medical decisions for the child? ☐ Joint ☐ Sole
If Sole, which parent?
With whom does the child reside?
Household 1: % time
Name of Parent or Guardian #1:
Names, ages, and relation to child of all other individuals in
the home:
Household 2 (if applicable): % time

Names, ages, and relation to child of all other individuals in
the home:
Page 1 of 9
Client Intake
Are both parents aware of services being sought at the UW Autism ☐ No ☐ Yes
Center?
Does your child have a Guardian Ad Litem? ☐ No ☐ Yes
If Yes, please provide their name:
Names and ages of any other siblings (i.e. those not living with the child):
5. Primary Language: ☐ English ☐ Other, specify

Percent time child is exposed to non-English language(s):
%
6. Primary Care Physician:

Clinic Name: Phone Number:
Address:
Medical History
Has the patient ever had or been diagnosed with any of the following conditions?
No Yes No Yes
Hearing Loss ☐ ☐ Seizures ☐ ☐
Vision or Eye Problems ☐ ☐ Sleep Problems ☐ ☐
Birth Defects ☐ ☐ Tics/ Movement Disorders ☐ ☐
Chronic Stomach/Bowel ☐ ☐ Genetic Disorders (e.g. ☐ ☐
Problems Fragile X, Tuberous Sclerosis, Down
syndrome, Rett Syndrome,
(ie: constipation, diarrhea, vomiting, reflux)
Neurofibromatosis)
Allergies (environmental, seasonal) ☐ ☐ Other Medical Conditions ☐ ☐
Multiple Ear Infections ☐ ☐ Autism/ASD ☐ ☐
Frequent or Chronic Headaches ☐ ☐ ADHD/ADD ☐ ☐
Head Abnormalities ☐ ☐ Depression ☐ ☐
Chronic Heart ☐ ☐ Mania / Bipolar Disorder ☐ ☐
Conditions/Disease
Lung Disease (Asthma, other) ☐ ☐ Obsessive-Compulsive ☐ ☐
Disorder
Kidney/Bladder/Genital ☐ ☐ Anxiety ☐ ☐
Problems
Chronic Skin Problems ☐ ☐ Schizophrenia ☐ ☐
Hormone/ Growth Problems ☐ ☐ Other Psychiatric Illnesses ☐ ☐
If you answered “Yes” to any of the above, please explain:
Page 2 of 9
Client Intake
Prior Medical Evaluations

1. Has the patient had any of the following evaluations?
If yes, results?:
Evaluation No Yes Unsure Norma Abnorma
l l
Audiologic Evaluation ☐ ☐ ☐ ☐ ☐
Vision Evaluation ☐ ☐ ☐ ☐ ☐
Head Imaging (MRI, CT or Ultrasound) ☐ ☐ ☐ ☐ ☐
EEG ☐ ☐ ☐ ☐ ☐
Genetic Testing ☐ ☐ ☐ ☐ ☐
Other Evaluations, Procedures, or ☐ ☐ ☐ ☐ ☐
Results
If any of the above were “Abnormal”, please explain:
No Yes If “Yes”, provide date &

2. Has the patient ever been ☐ ☐ explanation
hospitalized?
3. Has the patient had any surgeries? ☐ ☐
4. Are the patient’s immunizations up to ☐ No ☐ Yes ☐ Unknown

date?
Page 3 of 9
Medications & Biomedical Interventions
1. Is the patient currently taking any medications (prescribed or over the counter),
vitamins, or supplements?
Medication, Vitamin, Purpose Date Side Effects

or Started
Supplement Name
2. Does the patient follow any special diets or have special dietary needs? ☐ No ☐ Yes
If Yes, please explain:
3. Please list any other biomedical interventions:
None Yes If “Yes”, please explain.

known
4. Is the patient allergic to any ☐ ☐
medications?
5. Is the patient allergic to any foods? ☐ ☐
Pregnancy & Birth History

1. How old were biological parents at time of the patient’s birth? Biological mother:
Biological father:
2. How many times has biological mother been pregnant?
3. How many pregnancies have resulted in live births?
Pregnancy No Yes Unknown

1. Were there fertility treatments to become pregnant with the patient? ☐ ☐ ☐
2. Was the patient part of a multiple birth pregnancy? (e.g., twins) ☐ ☐ ☐
3. Did the birth mother take any medications, vitamins or supplements
during pregnancy? If Yes, please specify below. ☐ ☐ ☐
4. Did the birth mother use any alcohol, tobacco or drungs
during pregnancy? If Yes, please specify below. ☐ ☐ ☐
5. Were there any difficulties during pregnancy? (eg: bleeding, fever, infections,
abdominal trauma, decrease in fetal movement) ? If Yes, please specify below. ☐ ☐ ☐
Page 4 of 9
If “Yes” to any of the above, please explain:
Labor & Delivery and Neonatal Course
1. Was Pitocin used to induce or augment this labor? ☐ No ☐ Yes ☐ Unknown

2. The delivery was: ☐ Vaginal ☐ By C-section ☐ Unknown
If C-Section, reason performed:
3. Please provide the following information about the patient’s birth measurements:
Birth weight: lbs. & oz. / grams (circle one)
APGAR scores (if known): at 1 minute at 5 minutes
No Yes Unknown
4. Was the patient born premature? ☐ ☐ ☐
If Yes, how many weeks premature?
5. Were there complications during labor or delivery? ☐ ☐ ☐
6. Was any special resuscitation required or was the patient admitted ☐ ☐ ☐
to the NICU? If Yes, how old was the client when discharged? Days
7. Did the patient experience any problems while still in the hospital? ☐ ☐ ☐
(e.g. feeding problems, breathing difficulties, infections, jaundice, seizures)
If “Yes” to any of the above, please explain:
Family History
1. Please indicate if anyone in the patient's biological family ever had any of these conditions
(if so, please specify which family member, such as “mother”, “maternal grandmother”,
“paternal uncle”).
Condition: Family Member(s) Condition: Family Member(s)

Vision Problems Hearing Problems
Epilepsy/Seizures Tourette’s
Syndrome
Genetic Disorders Birth Defects
Multiple Miscarriages Childhood Deaths
or Stillbirths
Other Other
Neurologic Chronic
Disease Illnesses
Intellectual Disability Learning Difficulties
ASD (including autism, Speech &
Asperger syndrome, Language Delays
Page 5 of 9
& PDD-NOS)
Anxiety Obsessive-
Compulsive
Disorder
ADD/ADHD Depression
Bipolar Disorder Schizophrenia
Psychotic Episodes Suicide
Child Abuse Delinquency
Other Conditions: Other Conditions:
Page 6 of 9
Developmental History
1. Has the patient accomplished each of the following developmental milestones?
No Yes If yes, approximate age
(years)
Smile When Smiled At ☐ ☐
Pointing ☐ ☐
Walk (Independently) ☐ ☐
First Words other than ☐ ☐
Mama/Dada
First 2-3 Word Phrases ☐ ☐
Toilet Training: Bladder ☐ ☐
Toilet Training: Bowel ☐ ☐
Toilet Training: Night ☐ ☐
Use of Spoon or Fork ☐ ☐
2. Has the patient ever had loss or regression of a

previously learned skill? (e.g., language, motor, or social skill) ☐ No ☐ Yes
Educational History
1. Is the patient currently enrolled in school? ☐ No ☐ Yes
School Name: School District: Program or Grade level:
2. Is the patient receiving or has the patient received special services
or accommodations at school? ☐ No ☐ Yes
If Yes, please explain what type: (e.g. IEP, IFSP, 504 Plan)
3. Please list any school testing and/ or other evaluations of the patient’s learning skills:
A. Name of Provider / Agency:
Type of Evaluation: Date(s):
Result:
B. Name of Provider / Agency:
Type of Evaluation: Date(s):
Result:
4. Has the patient experienced any challenges related to reading, math or writing ☐ No ☐ Yes
5. Are there concerns around the patient’s organization, flexibility or attention? ☐ No ☐ Yes
Page 7 of 9
Behavioral & Social History
1. Please describe any behavioral concerns you have at this time:
2. Does the patient make friends easily? ☐ No ☐ Yes

If “No”, please explain:
3. Are there any concerns regarding the patient’s social skills or interests? ☐ No ☐ Yes
If “Yes”, please explain:
4. Are there any concerns regarding anxiety and/or depression? ☐ No ☐ Yes

5. Has the patient been exposed to any form of abuse, neglect or domestic violence? ☐ No ☐ Yes
6. Has the patient experienced any recent significant stressors (e.g. moves, losses)? ☐ No ☐ Yes
7. Are there concerns regarding any of the following areas?

No Yes If “Yes”, please explain
Responding to sound ☐ ☐
Responding to touch ☐ ☐
Responding to light ☐ ☐
Emotional reactions/regulation ☐ ☐
Aggression Towards Others ☐ ☐
Self-Injurious Behavior ☐ ☐
Difficulty with Transitions ☐ ☐
Page 8 of 9
Understanding social cues ☐ ☐
(e.g. gestures, facial cues)
Eye contact ☐ ☐
Inappropriate conversations ☐ ☐
Inappropriate Behavior ☐ ☐
Ritualistic behavior ☐ ☐
Repetitive behavior ☐ ☐
(e.g. hand flapping, rocking)
Fixation (e.g. computers, ☐ ☐
certain TV program, watching
spinning toy)
Toileting ☐ ☐
Other Concerns ☐ ☐
8. What are the patient’s interests and hobbies?
9. What are some of the patient’s strengths?
Additional Evaluations and Interventions

1. Has the patient ever been seen by an Occupational Therapist, Speech and Language
Therapist, Psychiatrist, Psychologist, or other mental health counselor? ☐ No
☐ Yes ☐ Unknown
If yes, please provide the following information:
A. Name: Type of Specialist Date of evaluation:
Purpose of Evaluation / Services:
Results of Evaluation:
B. Name: Type of Specialist Date of evaluation:
Purpose of Evaluation/ Services:
C. Name: Type of Specialist Date of evaluation:
Purpose of Evaluation:
Additional Comments
Please feel free to discuss any questions or concerns not covered above or to elaborate on
anything in the space below:
Page 9 of 9

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Client Intake

The following questionnaire is to be completed by the individual’s parent or

Identifying Information and Healthcare Provider (for Child Patient)

1. Patient’s Name: 2. Patient’s Date of Birth:

3. Name of Person completing form:

If the patient is a minor:

With whom does the child reside?

Household 2 (if applicable): % time

5. Primary Language: ☐ English ☐ Other, specify

6. Primary Care Physician:

If you answered “Yes” to any of the above, please explain:

Prior Medical Evaluations

If any of the above were “Abnormal”, please explain:

No Yes If “Yes”, provide date &

4. Are the patient’s immunizations up to ☐ No ☐ Yes ☐ Unknown

Medication, Vitamin, Purpose Date Side Effects

3. Please list any other biomedical interventions:

None Yes If “Yes”, please explain.

Pregnancy & Birth History

Pregnancy No Yes Unknown

Labor & Delivery and Neonatal Course

1. Was Pitocin used to induce or augment this labor? ☐ No ☐ Yes ☐ Unknown

If “Yes” to any of the above, please explain:

Condition: Family Member(s) Condition: Family Member(s)

2. Has the patient ever had loss or regression of a

1. Please describe any behavioral concerns you have at this time:

2. Does the patient make friends easily? ☐ No ☐ Yes

4. Are there any concerns regarding anxiety and/or depression? ☐ No ☐ Yes

7. Are there concerns regarding any of the following areas?

9. What are some of the patient’s strengths?

Additional Evaluations and Interventions

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