DEVELOPMENTAL HISTORY

Telecare acknowledges that it shall not claim to possess any right, title or interest in and to the following ASD Assessment and shall take no actions jeopardising the existence or enforceability of the proprietary rights which Telecare regonisises as belonging to Logan CYMHS.

PRIVATE & CONFIDENTIAL

Completed by one or both guardians of a patient

Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

Your Details

Relationship to the Patient *

Your name *

Patient Details

Patient's First Name *

Patient's Last Name *

Date of Birth *

At which stage of Education is the patient? *

Pre-school (day-care)Primary SchoolSecondary SchoolPost-secondary

QUESTIONNAIRE

⚠️ This Questionnaire typically takes over one hour to complete. For best results it is important to consider your answers which may require a certain degree of reflection

(Please provide detailed information for your reference and use later)

Pregnancy

1. How many pregnancies have you (mother) had? *

1. How many pregnancies has the mother of the subject had? *

2. Was this a planned pregnancy? *

YesNoUnsure

3. Did you (mother) have any health, including mental health, problems during the pregnancy? *

YesNo

3. Did the subject's mother have any health, including mental health, problems during the pregnancy? *

YesNoUnsure

4. Were you on any medication during this pregnancy? *

YesNo

4. Was the subject's mother on any medication during this pregnancy? *

YesNoUnsure

5. During pregnancy, did you (mother) drink alcohol? *

YesNo

5. During pregnancy, did the subject's mother drink alcohol? *

YesNoUnsure

6. During pregnancy, did you (mother) smoke cigarettes? *

YesNo

6. During pregnancy, did the subject's mother smoke cigarettes? *

YesNo

7. During pregnancy, did you (mother) use any illicit substances? *

YesNo

7. During pregnancy, did the subject's mother use any illicit substances? *

YesNoUnsure

Birth

8. Was s/he premature or born at full term? *

9. Type of delivery? *

10. Birth weight? *

11. Did he/she require any resuscitation at birth? *

YesNo

12. Did s/he need to go to Special Care Baby Unit? *

YesNo

13. How long were you in hospital for? *

Infancy / young child

15. What was s/he like as a baby? eg. settled, difficult to settle. *

16. Was s/he easy to get into a routine? *

YesNo

17. How did s/he sleep? *

18. How did you bond? Any postnatal depression? *

19. Did you breast or bottle feed? *

20. Did s/he make eye contact during feeding? *

YesNo

21. How old was s/he when weaned to solids? Any difficulties? *

22. Any feeding difficulties? *

YesNo

23. Did s/he like to be held? Could you comfort him/her? *

YesNo

24 Was s/he hard to keep busy? *

YesNo

25. Was he/she overactive? *

YesNo

26. Was s/he stubborn or challenging? *

YesNo

27. Did s/he show a normal wide range of emotions, or were they quite flat emotionally? *

28. Was s/he affectionate? Would s/he seek comfort? Would s/he try to comfort others if upset? *

YesNo

29. Was s/he sociable eg would point at things, look at what you were looking at, want to show you things they liked? *

YesNo

30. How did s/he let you know he/she wanted something before they could speak? *

31. Did s/he use non-verbal communication including pointing, eye contact? *

YesNo

32. Did s/he ever use your hands like a tool eg. to open something? *

YesNo

33. Did s/he ever imitate adults eg. pretend to brush their hair, sweep? *

YesNo

Milestones

34. How old was s/he when:

Crawled: *

Walked: *

Babbled: *

First word: *

Put two words together: *

Speak in sentences: *

Dry during the day: *

Dry at night: *

Day Care

35. Did s/he go to day care? At what age? *

YesNo

36. How did s/he cope separating from you? *

37. How did s/he interact with the other children? *

38. Did s/he play with other children or play beside them? *

39. Did day care staff have any concerns about your child? *

YesNo

Primary Education

⚠️ Questions in this field will be hidden as they are not applicable to the subject

40. What age was s/he when he went to primary school? *

41. How did s/he cope with the transition to primary school? *

42. How did s/he do academically at primary school? *

43. How did s/he interact with other children at primary school? Did he/she have friends? What was the quality of these friendships? *

44. Does s/he make friends easily? Or does s/he have difficulty keeping friends? *

45. Did the teachers raise any concerns at primary school? *

YesNo

Secondary Education

⚠️ Questions in this field will be hidden as they are not applicable to the subject

46. What age was s/he when he went to high school? *

47. How did s/he cope with the transition to high school? *

48. How did s/he do academically at high school? *

49. How did s/he interact with peers at high school? Did s/he have friends? What was the quality of these friendships? *

50. Have the teachers raised any concerns at high school? *

YesNo

51. Does s/he have/had a job? *

YesNo

52. How has s/he coped with having a job? *

53. Age when s/he left school? What has s/he done since? Any difficulties in these settings? *

Adolescents

⚠️ Questions in this field will be hidden as they are not applicable to the subject

⚠️ This question is only applicable to subjects over the age of 10 years old. Please select not applicable if the subject does not fit into this age range.

54. Does s/he understand humour? Sarcasm? *

YesNoNot applicable

55. Does s/he understand metaphors? *

YesNoNot applicable

For all questions below, please provide details about the nature of the difficulties

⚠️ Please answer the following questions to the best of your ability. Some questions may not be applicable; if so please select "Not applicable" or type "N/A" into the relevant text box.

R1. Thinking about his/her school work and about his/her ability to reason things out, is s/he about average for his/her age, ahead, or behind? *

AheadAverageBehindNot Applicable

R2. At present, roughly what sort of age level is s/he at in his/her school work and ability to reason things out? (Optional: For example like an average [insert an age 2 years younger than the child's chronological age] year old?) *

R3. Is his/her ability to use language - to say what s/he means and to understand what other people are saying - about average for his/her age, ahead or behind? *

AheadAverageBehind

R4. At present, roughly what sort of age level is s/he at in his/her use and understanding of language? (Optional: For example like an average [insert an age 2 years younger than the child's chronological age] year old?) *

R5, Can s/he get around difficulties in explaining what s/he wants to say by other means, for example by using gestures, signs, facial expressions or acting things out? *

NoA littleA lot

R7. Have the things that seriously worried you or someone else now cleared up completely? *

Cleared up completelySome continuing problemsThere were no worries

⚠️ Skip rule for the rest of this section!

Only continue if R7 = 'Some continuing problems', or if the SDQ peer problem score is 2 or morepoints higher than the prosocial score. Otherwise go to next section.

If you did not select "Some continuing problems' you will be unable to view questions R8 - R43

If R6a = 'Yes', please answer R8 and R9, otherwise skip to R10

R8. Could s/he use any real words other than 'mama' or 'dada' before the age of 2 years? (Baby words such as 'bickie' for 'biscuit' do count. Exclude other words for mother or father) *

NoYes

R9. After using single words, children go on to join them up into phrases or short sentences like 'Go park see ducks' or 'Mama give biscuits'. Did s/he join words together into phrases or short sentences before the age of 3 years? (Do not count set phrases like 'Thank you' or 'Night night' that the child uses as just one word) *

NoYes

R10. Toddlers often communicate through physical gestures such as waving goodbye, pointing to things, blowing a kiss, or bringing a finger to their mouth and saying Shh! Whens/he was a toddler, did [Name] use these sorts of gestures as much as other children of the same age? *

About the same/moreA little lessA lot less

R11. Some children like playing nursery games like Ring a Ring a Roses, Round and Round the Garden, Peekaboo. Did s/he ever like these games? *

NoA littleA lot

R12. Young children often try to share their enjoyment or interests or achievements, for example by pointing out something that they think you will enjoy seeing or find interesting. As a toddler and young child, did s/he want to share his/her enjoyment, interests or achievements with other people? *

NoA littleA lot

R13. Some children spend a lot of their play time repeating the same action over and over again, for example spinning the wheels on a toy car, turning taps or light switches on and off, or opening and shutting doors. Has this ever been true of him/her? *

NoA littleA lot

R14. Children are sometimes very interested in unusual aspects of toys or other things. For example, rather than playing with a toy, they may spend their time sniffing it, or running their fingers over its surface, or holding it to their face to feel any vibration that it makes. Has this ever been true of him/her? *

NoA little A lot

Make-believe play is important to some children. This can include pretend games with other children - games such as cops and robbers, or mummies and daddies. Even when they are by themselves, children may act out stories with dolls, action men or make-believe objects.

Is the subject under the age of 11? (This is required for R15 & R16) *

NoYes

R15. As a preschool child and more recently, has s/he taken part in make-believe play? *

NoA little A lot

R15. Thinking about when s/he was younger (say between 5 and 10), did s/he take part in make-believe play? *

NoA little A lot

R16. At present, can s/he make allowances according to who s/he is playing with? For example, not being too rough when playing with younger children, and not being too bossy when playing with older children. *

NoA little A lot

R16. Whens/he was younger (say around 10), could s/he make allowances according to who s/he was playing with? For example, not being too rough when playing with younger children, and not being too bossy when playing things with older children. *

NoA little A lot

R17. When s/he' s with other children/teenagers, does s/he have difficulty taking turns, sharing or co-operating? *

NoA little A lot

R18. Some children/teenagers enjoy putting a lot of time into collecting things, or get a lot of pleasure out of focusing on just one topic, such as sport, cars or a particular pop group. In everyday language, we often say that these children/teenagers are 'obsessed' by their interest, but this is not an unpleasant obsession - this is something they like and usually enjoy talking about. Has s/he had any long-lasting obsessions of this sort? *

NoA little A lot

R19. Obsessions may be about common or unusual topics. For example, it is fairly common for an 8 year old to be obsessed by dinosaurs, but it is unusual for an 8 year old to be obsessed by Victorian fireplaces, bar codes or street lamps. Is or was the topic of his/her obsession unusual? *

NoA little A lotNot Applicable

R20. Does or did the obsession dominate his/her life? *

NoA little A lotNot Applicable

R21. Does or did it tend to dominate his/her conversation with other people? *

NoA little A lotNot Applicable

R22. Does or did it stop him/her doing other important things in his/her life, such as playing, studying or going out? *

NoA little A lotNot Applicable

R23. Please describe the obsession *

R24. Is s/he able to start conversations with other people? *

NoA little A lot

R25. If other people start conversations with him/her, can s/he keep the conversation going? *

NoA little A lot

R26. Is s/he genuinely interested in chatting with other I peqple in order to hear what they have to say about their experiences and interests - even if those interests are different from his/her own interests? *

NoA little A lot

R27. Some children/teenagers have trouble adjusting their language to suit different social occasions. For example, they may speak too casually to a teacher or too formally to other children. Does s/he change the ways/he speaks according to whether it is a formal or informal situation? *

NoA little A lot

R28. It is relatively easy to tell what some children/teenagers aie feeling by observing their facial expressions, their tone of voice and their body language. It is harder to tell with other children/ teenagers, particularly if you don't know them very well. Do most people have difficulty knowing what s/he is feeling by observing his/her face, body language or tone of voice? Please describe. *

NoA little A lot

R29. The other way round, children/teenagers vary in their ability to know what other people are feeling. Some children/ teenagers are good at recognising subtle clues in body language, facial expressions, or tone of voice. For example, they can immediately tell when their mother is starting lo get a little cross, or when another child/teenager is feeling a bit embarrassed. Other children/teenagers find this much harder. Does s/he have difficulty recognising the clues in other people's facial expressions, body language and tone of voice? Please describe. *

NoA little A lot

R30. When we're talking with someone face-to-face, eye contact is very important. It generally makes us feel uneasy, or as if there's something wrong, if the other person makes too little eye contact, or too much, or makes it at the wrong time. Has s/he ever been through a phase of making too I I little or too much eye contact, or making it in the wrong sort of way? Please give examples. *

NoPerhapsDefinitely

R31. Many young children go through a phase of repeating what someone has just said to them. For example, if you said, "We'll be going home in a few minutes", they might parrot back "We'll be going home in a few minutes". Or they might echo back the last word, "minutes", in your tone of voice. Some young people do this a lot. Has s/he ever echoed or parroted speech in this way? Please give examples. *

NoA little A lot

R32. Some children/teenagers ask the same questions over and over again. For example, ''When are we going to the park?" or "What's for dinner?" or "Are we going swimming this weekend?" They keep repeating these questions even though they've already been told the answers many times. The questions that are repeated may not be exactly the same from week to week. Has s/he ever tended to ask repetitive questions? Please give examples. *

NoA little A lot

R33. Another way in which young people repeat themselves is by using the same catch-phrase or cliché over and over again. For example, almost every sentence may begin "If you want my opinion ... " or "Logically speaking..." Occasionally the phrase is appropriate, but it is used far more than is really needed. Has s/he ever filled his/her speech with these fairly empty catch-phrases or cliches? Please give examples. *

NoA little A lot

R34. Some children enjoy routines and want things to be the same every day. For example, they may want to eat the same food off the same plate while sitting in the same chair every single day. Or there may be very fixed routines for dressing or undressing. Has s/he ever had strong or unusual routines that s/he has insisted on because s/he enjoyed doing it that way? *

NoA little A lot

R35. Please describe these routines *

R36. Some children are easily upset by small changes in their routines. For example, they may be very upset by having to go to school a different way, by having to take a bath at a slightly different time, or by the furniture being moved around. Has s/he ever been easily upset by changes in routine? Please describe. *

NoA little A lot

R37. Some preschool children go through a phase of flapping or waving their hands or arms up and down if they are excited or upset. Some continue doing this for years. Since s/he has been going to school, has s/he tended to flap his/her arms when excited or upset? *

NoA little A lotNot Applicable

R38. You have answered a lot of questions about his/her pattern of development - focusing particularly on language, play, routines and his/her ability to get along with other people. Are you concerned at present about any of these aspects of his/her development? Please describe. *

NoA little A lot

R39. Thinking about the last 12 months, have difficulties in any of the areas that we have covered resulted in him/her becoming upset or distressed? *

Not at allA littleA medium amountA great deal

R41. Have these difficulties put a burden on you or the family as a whole? *

Not at allA littleA medium amountA great deal

R42. Some children's development is unusual from birth onwards. With hindsight, their parents realise that development was never quite normal. That's not always the case though. Sometimes parents are sure that development was completely normal for a while and then there was a relatively sudden change. Which was true for him/her? *

Always there to some extentSudden change

R43. How old was s/he when this change happened?

SENSORY INFORMATION

R44. Some children don't seem to react to pain or extreme heat or cold - sensations that would R44 bother most people. Has s/he ever seemed unconcerned about pain or other unpleasant sensations? *

NoA little A lot

R45. Some children are fascinated by particular sounds, smells and other sensations - and focus on them in an unusual way. Examples include: sniffing people, spending hours looking at the window frame at a particular angle, or looking at their own fingers against the light. Has s/he ever been really fascinated by particular sensations? Please describe. *

NoA little A lot

R46. Children may react surprisingly negatively to specific sounds, tastes, sights and so on. For example, some children get really upset by the sound of the phone ringing or people coughing. There are endless possibilities, but other examples include reacting particularly badly to the smell of a perfume, the taste of vanilla or the sight of a vacuum cleaner. Has ever been over-sensitive to particular sensations? Please describe. *

NoA little A lot

R47. Some children have an unusual response to touch. For example, they may overreact to touch (such as jumping if you put your hand on their shoulder, hate having their hair brushed or washed, or dislike the feel of labels/tags in clothing) or may not respond to things that others find uncomfortable (such as big strong bear hug, or squashing themselves behind furniture). Has s/he ever had unusual responses to touch? *

NoA little A lot

Have you ever experienced any traumatic event like being touched when you didn't want to or witnessing/being part of an accident or witnessing/being part of violence at home? *

YesNo

The above questions relate to specific diagnostic criteria in a DSM-V as indicated in the table below:

Code	DSM-V Criterion	Brief Description	Relevant Questions
Gen and Imp provide general information about development and impact of difficulties			R1, R2, R3, R4, R5, R6, R7, R8, R9, R38, R39, R40, R41, R42, R43
SE	A1	Socio-emotional reciprocity	R24, R25, R26
NV	A2	Non-verbal communication	R10, R11, R12, R28, R29, R30
Rel	A3	Relationships	R16, R17, R27
Rep	B1	Stereotyped and repetitive movement & behaviour	R13, R31, R32, R33, R37
RR	B2	Preference for routine and resistance to change	R34, R35, R36
OB	B3	Obessional behaviour and tendencies	R18, R19, R20, R21, R22, R23
Un	B4	Unusual interests and sensory responses	R14, R15
Sen	n/a	Sensory processing	R44, R45, R46, R47

CHILD'S HEALTH

Has he/she had any health problems? *

YesNo

Has he/she been in hospital? *

YesNo

Has he/she had any operations? *

YesNo

Is he/she on any medication? *

YesNo

Does he/she have any allergies? *

YesNo

FAMILY MEDICAL HISTORY

Please note the family member's relationship to the child in regard to the following:

Simply write N/A in the box if there is no relevant family history

Family relationship with Mental Illness (describe) *

Family relationship with ADHD *

Family relationship with ASD *

Family relationship with Suicide *

Family relationship with Drug or alcohol misuse *

Family relationship with Diabetes *

Family relationship with Epilepsy *

Family relationship with Cardiac Arrhythmia *

Family relationship with Sudden death *

Family relationship with Neurological disease *

Family relationship with Learning problems / special school / illiterate *

SIGNATURE

I confirm the above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature *

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Today's Date *

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