Medical Assessment Form
Please provide your information and describe your current symptoms for a medical evaluation.
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Please describe your current symptoms or concerns
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I am a sympathetic person.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I often use words and phrases from movies and television in conversations.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am often surprised when others tell me I have been rude.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes I talk too loudly or too softly, and I am not aware of it.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I often don’t know how to act in social situations.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I can “put myself in other people’s shoes” .
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have a hard time figuring out what some phrases mean, like “you are the apple of my eye”.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I only like to talk to people who share my special interests.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I focus on details rather than the overall idea.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I always notice how food feels in my mouth. This is more important to me than how it tastes.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I miss my best friends or family when we are apart for a long time.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes I offend others by saying what I am thinking, even if I don’t mean to.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I only like to think and talk about a few things that interest me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I’d rather go out to eat in a restaurant by myself than with someone I know.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I cannot imagine what it would be like to be someone else.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have been told that I am clumsy or uncoordinated.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Others consider me odd or different.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I understand when friends need to be comforted.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am very sensitive to the way my clothes feel when I touch them. How they feel is more important to me than how they look.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like to copy the way certain people speak and act. It helps me appear more normal.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It can be very intimidating for me to talk to more than one person at the same time.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have to “act normal” to please other people and make them like me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Meeting new people is usually easy for me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I get highly confused when someone interrupts me when I am talking about something I am very interested in.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It is difficult for me to understand how other people are feeling when we are talking.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like having a conversation with several people, for instance around a dinner table, at school or at work.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I take things too literally, so I often miss what people are trying to say.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It is very difficult for me to understand when someone is embarrassed or jealous.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Some ordinary textures that do not bother others feel very offensive when they touch my skin.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I get extremely upset when the way I like to do things is suddenly changed.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have never wanted or needed to have what other people call an “intimate relationship”.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It is difficult for me to start and stop a conversation. I need to keep going until I am finished.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I speak with a normal rhythm.
True now and when I was young
True only now
True only when I was younger than 16
Never true
The same sound, colour or texture can suddenly change from very sensitive to very dull.
True now and when I was young
True only now
True only when I was younger than 16
Never true
The phrase “I’ve got you under my skin” makes me very uncomfortable.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes the sound of a word or a high-pitched noise can be painful to my ears.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am an understanding type of person.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I do not connect with characters in movies and cannot feel what they feel.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I cannot tell when someone is flirting with me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I can see in my mind in exact detail things that I am interested in.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I keep lists of things that interest me, even when they have no practical use (for example sports statistics, train schedules, calendar dates, historical facts and dates).
True now and when I was young
True only now
True only when I was younger than 16
Never true
When I feel overwhelmed by my senses, I have to isolate myself to shut them down.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like to talk things over with my friends.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I cannot tell if someone is interested or bored with what I am saying.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It can be very hard to read someone’s face, hand and body movements when they are talking.
True now and when I was young
True only now
True only when I was younger than 16
Never true
The same thing (like clothes or temperatures) can feel very different to me at different times.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I feel very comfortable with dating or being in social situations with others.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I try to be as helpful as I can when other people tell me their personal problems.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have been told that I have an unusual voice (for example flat, monotone, childish, or high-pitched).
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes a thought or a subject gets stuck in my mind and I have to talk about it even if no one is interested.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I do certain things with my hands over and over again (like flapping, twirling sticks or strings, waving things by my eyes).
True now and when I was young
True only now
True only when I was younger than 16
Never true
I have never been interested in what most of the people I know consider interesting.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am considered a compassionate type of person.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I get along with other people by following a set of specific rules that help me look normal.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It is very difficult for me to work and function in groups.
True now and when I was young
True only now
True only when I was younger than 16
Never true
When I am talking to someone, it is hard to change the subject. If the other person does so, I can get very upset and confused.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes I have to cover my ears to block out painful noises (like vacuum cleaners or people talking too much or too loudly).
True now and when I was young
True only now
True only when I was younger than 16
Never true
I can chat and make small talk with people.
True now and when I was young
True only now
True only when I was younger than 16
Never true
Sometimes I have to cover my ears to block out painful noises (like vacuum cleaners or people talking too much or too loudly).
True now and when I was young
True only now
True only when I was younger than 16
Never true
When talking to someone, I have a hard time telling when it is my turn to talk or to listen.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am considered a loner by those who know me best.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I usually speak in a normal tone.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like things to be exactly the same day after day and even small changes in my routines upset me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
How to make friends and socialize is a mystery to me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It calms me to spin around or to rock in a chair when I am feeling stressed.
True now and when I was young
True only now
True only when I was younger than 16
Never true
The phrase, “He wears his heart on his sleeve,” does not make sense to me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
If I am in a place where there are many smells, textures to feel, noises or bright lights, I feel anxious or frightened.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I can tell when someone says one thing but means something else.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like to be by myself as much as I can.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I keep my thoughts stacked in my memory like they are on filing cards, and I pick out the ones I need by looking through the stack and finding the right one (or another unique way).
True now and when I was young
True only now
True only when I was younger than 16
Never true
The same sound sometimes seems very loud or very soft, even though I know it has not changed.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I enjoy spending time eating and talking with my family and friends.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I can’t tolerate things I dislike (like smells, textures, sounds or colours).
True now and when I was young
True only now
True only when I was younger than 16
Never true
I don’t like to be hugged or held.
True now and when I was young
True only now
True only when I was younger than 16
Never true
When I go somewhere, I have to follow a familiar route or I can get very confused and upset.
True now and when I was young
True only now
True only when I was younger than 16
Never true
It is difficult to figure out what other people expect of me.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I like to have close friends.
True now and when I was young
True only now
True only when I was younger than 16
Never true
People tell me that I give too much detail.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I am often told that I ask embarrassing questions.
True now and when I was young
True only now
True only when I was younger than 16
Never true
I tend to point out other people’s mistakes.
True now and when I was young
True only now
True only when I was younger than 16
Never true
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