Center of Excellence Autism Evaluation
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Birth History
Was your child born...
Full-term?
Premature?
If premature, how many weeks?
Were there any complications during pregnancy?
Was there any exposure to any of the following during pregnancy?
Prescription Medications
Alcohol
Cigarettes/Vaping
Marijuana
Illicit Drugs
Other
Please describe any of the above answers and include which substance and frequency of use.
Were there any difficulties with the delivery or after delivery?
Early Childhood and Development
Please indicate at what age your child met the following milestones. If not yet met, please mark that box.
Age
Not Yet Met
Smiling
Cooing
Rolling
Sitting Independently
Walking
Said First Word
Pottytrained
Does your child attend daycare or school?
Yes
No
Describe how your child gets along with other children.
Parental Concerns
What concerns have you had about your child and his/her behavior?
At what age did you first notice these behaviors?
Has your child had any of the following?
Assessment by a neurologist or developmental specialist
Therapy services including OT, PT, Speech or Feeding Therapy
An IEP
Psychological or psychiatric evaluation
Child Find evaluation
Hearing or vision screening
Other
If yes to any of the above, please describe.
Family History
Please indicate if there are any family members with the following diagnoses.
Yes
Which Family Member(s)?
ADHD
Anxiety
Autism Spectrum Disorder
Depression
Developmental Delay
Fragile X
Genetic Disorders
Learning Disorders
Submit
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