Autism Census Step 1 of 12 8% General InformationMother Name First Last Mother Date of Birth Mother AgeMother OccupationFather Name First Last Father Date of Birth Father AgeFather Occupation Married Divorced Separated Single Child Name First Last Child Date of Birth Age (Years)Age (Months)Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail* EthnicityCaucasianLatinAfrican AmericanAsianAge of Diagnoses (Year)Age of Diagnoses (Month)How did you get the diagnoses?MailIn personDiagnosesAutismAsperger'sWhat do you think caused it? Genetics Vaccination Difficult Pregnancy Select all that applyWhat therapies helped?What therapies did not help?What medications helped?What medication did not help? Current Concerns aggression has few friends has no friends over activity language difficulties toilet training preoccupations temper tantrums biting hitting focus self-injury sleep problems argumentative easily distracted self-help skills motor skills has nightmares nervousness depressed or anxious muscle tone won't take baths appetite/food eats things that aren't food wets the bed pulls out own hair inattentive school adjustment cruel to animals inappropriate sexual behavior self-stimulatory behaviors: rocking, spinning, flapping hands, visual scrutiny socialization Other: Developmental HistoryPrenatal / PregnancyDid the biological mother have any of the following immediately before/after or during pregnancy? Maternal Injury Hospitalization during pregnancy X-rays during pregnancy Describe Maternal InjuryReason for hospitalization during pregnancyWhat month of pregnancy did the mother have x-rays?Did the biological mother have any of the following during pregnancy? Emotional problems Infections Premature Labor Rashes Bed-rest Toxemia Difficulty in conception Anemia Gained more than 35 pounds Excessive swelling Vaginal bleeding Measles/German measles Excessive nausea/vomiting Flu High blood pressure Kidney disease Strep Throat Threatened miscarriage Rh incompatibility Headaches Severe cold Urinary problems Other virus Mother's age at conception:Did the mother have previous pregnancies?YesNoHow many previous pregnancies (including miscarriages)?During the pregnancy, was the babyVery activeAverageRather quietWere there any unusual changes in the baby’s activity level during pregnancy?NoYes DeliveryWas infant born full-term?YesNoIf premature, how early?If overdue, how late?Birth Weight (lbs oz)Type of anesthetic used:NoneSpinalLocalGeneralLength of labor:Describe any complications during laborWhich of the following applied to the infant? Breathing problems Required oxygen Required incubator Jaundice Feeding Problems Sleeping Problems Infection Rash Excessive crying Seizures/convulsions Bleeding into the brain Were Bilirubin lights used?NoYesHow long?Did the infant require: X-rays CT scans Blood transfusions Placement in the NICUNoYesHow long in the NICU?Length of stay in hospital - Mother:Length of stay in hospital - Infant: Early Childhood HistoryDuring this child's first three years, were any special problems noted in the following areas? Irritability Breathing problems Colic Difficulty sleeping Eating problems Temper tantrums Failure to thrive Excessive crying Withdrawn behavior Poor eye contact Early learning problems Destructive behavior Convulsions/Seizures Twitching Unable to separate from parent OtherMilestones - Indicate age when child:Sat unaidedCrawledWalkedStarted solid foodsFed self with spoonGave up bottleBladder trained - dayBladder trained - nightBowel trainedRides tricycleRides tricycleRides bikeCan child be described as clumsy/uncoordinated?YesNoHaving fine motor delay?YesNoWhich hand does your child use for writing/drawing?LeftRightWhich hand does your child use for eating?LeftRightWhich hand does your child use for cutting?LeftRightCurrent eating behavior: Normal Picky Eats too much Weight loss/gain Oral Motor concerns None Difficulty swallowing Drooling Gagging Language DevelopmentIndicate age when child begin babbling, such as repeating syllables, in attempts to communicateUsing single words?Using phrases/short sentences?Have there been any hearing concerns?NoYes Hearing TestingAdaptive SkillsFeeds selfNoYesBeginning at age:Dresses selfNoYesBeginning at age:Bathes selfNoYesBeginning at age:Helps with household chores?NoYesBeginning at age:Knows first and last nameNoYesBeginning at age:Says “please” and “thank you”NoYesBeginning at age:Able to walk up/down stairsNoYesBeginning at age:Has the child ever lost skills, which at one time he/she was able to perform?NoYesWhen your child is disruptive or misbehaves, what steps are you likely to take to deal with the problem? Time out Loss of allowance/privileges Physical punishment Yelling Ignoring Grounding Other, describe:Who is mainly in charge of discipline?MomDadWhat do you find most difficult about raising your child? Medical HistoryHas your child ever had a Head Injury?YesNoAgeDescribeHas your child ever had loss of consciousness?YesNoAgeDescribeAllgeries to food/medication List:SurgeryYesNoAgeReasonEar InfectionsYesNoAgeDescribeEar Tubes?NoYesIs the child up to date on immunizations?YesNoWhat immunizations has your child been given?Doctors seen (check all that apply) Pediatrician Developmental Pediatrician Neurologist Genetics Psychiatry Psychology Gastroenterology Endocrinology Developmental Pediatrician -DiagnosisNeurologist –Diagnosissuspected seizures, describeseizures diagnosed, type:Genetics – DiagnosisPsychiatry – DiagnosisGastroenterology – Diagnosis:stomach/intestinal problems, type:Endocrinology – Diagnosis: Medication HistoryCurrent MedicationName of medicationDose & FrequencyDate StartedReasonEffectiveness (1 - 10)Please also list any medications your child has been on in the PAST:Date Started Date Ended ReasonEffectiveness (1 - 10)Who prescribed past medications? Please mark any of the following in each area that describe your child currently or in the past:Speech:slow speech development Past Current doesn't understand without gestures Past Current unusual tone or pitch Past Current repeats words/phrases over and over Past Current difficulty to understand speech Past Current repeats questions, instead of answering them Past Current seldom speaks unless prompted Past Current repeats dialogue from movies/songs verbatim Past Current has language of his/her own (may sound like foreign language/jargon) Past Current Relating with other peopleprefers to be by self Past Current “in a world of his/her own” Past Current aloof, distant Past Current clings to people Past Current fearful of strangers Past Current not cuddly as baby Past Current doesn’t like to be held Past Current doesn’t recognize parent Past Current doesn’t play with other children Past Current prefers playing with younger or older children Past Current Imitationdoesn’t imitate waving “bye-bye” or “patty cake” etc. (physical imitation) Past Current doesn’t repeat words/things said to him Past Current doesn’t repeat words generally, but usually did what he was asked to do Past Current Response to Sounds, Speechoften ignores sounds Past Current often ignores what is said to him/her Past Current afraid of certain sounds Past Current really likes certain sounds (music, motors, etc.) Past Current seems to hear distant or soft sounds that most other people don’t hear or notice Past Current unpredictable response to sounds (sometimes reacts, sometimes doesn’t) Past Current responds to speech and sounds like other children of the same age Past Current Visual Responsestares vacantly around room Past Current plays with turning lights on and off Past Current often doesn’t look at things Past Current distracted by lights – stares at certain lights Past Current likes to look at self in mirror Past Current very interested in small parts of an object Past Current likes to look at shiny objects Past Current looks at things out of the corners of eyes Past Current stares at parts of his/her body (e.g. hands) Past Current often avoids looking at people when they are talking to him Past Current Other Sensesputs many objects in mouth Past Current likes vibrations Past Current licks objects Past Current doesn’t notice pain as much as most people Past Current overreacts to pain Past Current smells objects unusual or unfamiliar objects Past Current chews or eats objects that are not supposed to be eaten Past Current Emotional Responsestemper tantrums Past Current laughs/smiles for no obvious reason Past Current overly responds to situations Past Current moods change quickly/for no apparent reason Past Current cries/seems sad for no obvious reason Past Current often has blank expression on face Past Current little response to what is happening around him/her Past Current Family Medical / Psychiatric HistoryHave any members of the biological mother’s or biological father’s families had any of the following problems or disorders (check all that apply): Birth Defect Chromosomal/genetic disorder Obsessive Compulsive Disorder Cerebral Palsy Severe head injury High blood pressure Kidney disease Migraine headaches Multiple Sclerosis Physical handicap Nervousness/Anxiety Stroke Tuberous Sclerosis Alzheimer’s disease Hemophilia Huntington’s chorea Muscular dystrophy Parkinson’s disease Sickle-cell anemia Cancer Seizures/epilepsy Diabetes Heart disease Food allergies Alcohol/drug abuse Depression Physical/Sexual abuse Schizophrenia Mental Retardation Speech/language delay Autism/PDD Reading problem Other learning disability Emotional disturbance/mental illness Bipolar/manic-depressive disorder Tics/Tourette’s syndrome Antisocial Behavior(assaults, thefts, arrests) Childhood behavior disorder (aggressive/defiant/ADHD) Other:Has anyone in the family ever received special education services?YesNoIf Yes, for what reason?Family Changes and StressorsPlease indicate any major family stresses the family and/or child is currently experiencing or has experienced within the last year Marital discord/fighting Separation Divorce Birth/Adoption of another child Sibling conflict Parent-Child conflict Custody disagreement Single-parent family Parent/sibling death Parent deployed extensively Parent emotionally/mentally ill Involved in juvenile court Abandonment by parent Financial problems Parent substance abuse Child Neglect Physical abuse Sexual abuse Parental disagreement about child-rearing Involved with Social Services/Child Protective Services Other, if not listed: School HistoryCurrent school:School district:Grade level:Type of Class:Regular EdSpecial EdResourceEDBehavioral unitCurrent Number of Teachers:Current Number of Aides:Does your child have a 1:1 Aide?YesNoHas your child had special education testing in school?YesNoPsychological/Cognitive – Date: Academic – Date: Speech/Language – Date: Other – Date: Is your child receiving any special education services at school?YesNoIs your child on an IEP (Individual Education Plan)?YesNoFor what reason?Please list all of the schools, including preschools, your child has attended:Name of SchoolAgeGradeHours per dayDays per week ServicesPlease list services your child has received. Speech Therapy Occupational Therapy Physical Therapy Adaptive Physical Education Discrete Trial Training (DTT/ABA) Social Skills Other - describe:Child’s age when school services began:Individual Education Plan (IEP) eligibility:Which services is your child CURRENTLY receiving through the SCHOOL DISTRICT? Speech Therapy Occupational Therapy Physical Therapy Adaptive Physical Education Discrete Trial Training (DTT/ABA) Social Skills Other - describe:Early Childhood Intervention (ECI):Child’s age when ECI services began:Which services is your child CURRENTLY receiving through the REGIONAL CENTER? Speech Therapy Occupational Therapy Physical Therapy Adaptive Physical Education Discrete Trial Training (DTT/ABA) Social Skills Other - describe:Private ServicesAre you or your insurance company currently paying for services to address your child’s needs?YesNoSpeech therapy Provided by:Age when began:Occupational therapy Provided by:Age when began:Physical therapy Provided by:Age when began:Adaptive Physical Education Provided by:Age when began:Social Skills Provided by:Age when began:Discrete Trial Training(DTT/ABA) Provided by:Age when began:Other - describe:Would you like to be notified of new treatment options when available?YesNoHas your child ever lost their diagnoses?YesNoWhy?Thank you for completing the census. On submission of the form the Best Advice I Ever Got free e-book will be emailed to the email address you entered at the beginning of the census. You will also be directed to The Autism Lab web site. Be sure to sign up for our newsletter while you are there.