Adult Autism Assessment Background Information FormAdult Autism Assessment Background QuestionnaireStep 1 of 714%Personal InformationName First Last First name you would like used throughout reportDate of Birth DD slash MM slash YYYY Personal InformationAs part of the assessment, we will need to gather information about your development, both on this form and during an interview. If you have an informant who knew you as a child, who would be willing to be part of the assessment please provide their details below. If you do not have an informant who knew you as a child we can work with someone you have lived with for more than 2 years, such as your partner. Please provide their contact details below instead. If you do not have an informant we can undertake the whole assessment with you.Informant’s name First Last Informant’s phone numberInformant’s email address Informant’s relationship to youCurrent ConcernsWhat difficulties are you experiencing at the moment?Have you ever experienced any distressing life experiences such as the loss of a loved one, accident or other traumatic event? If so, please provide detailsWhat is your sleep pattern like?Professional InvolvementWhat, if any, professionals are currently involved with you or have you been referred to? (please list professional's name, role, service and if they are involved or referred).Family BackgroundWho lives at home with you currently?If different, who did you live with when growing up?Please provide details of any family members with neurodevelopmental conditions or specific learning difficulties such as autism, dyslexia. ADHD or learning disabilityPlease provide details of any family members with mental health difficulties such as anxiety, depression or schizophreniaMedical HistoryDo you have any medical diagnoses? if so please list belowPlease list any medications that you are prescribedDo you have any vision or hearing problems?Have you ever sustained a head injury?DevelopmentPlease write ‘I don’t know’ if you cannot obtain this informationWere there any issues with your mother’s pregnancy?Were there any complications during birth?At how many weeks were you born and what did you weigh at birth?Were there any concerns during the first 6 weeks?What were you like as a baby?At what age did you first walk unaided?At what age did you say your first meaningful words?At what age did you say your first phrases?Did you ever lose language or other skills after gaining them?At what age were you dry by day?At what age were you dry by night?At what age did your parents first have concerns about your development?EducationPlease list all education settings name and dates attended (including pre-school)Education SettingsHow did you first settle into school or nursery?How did you feel about school now?What did your teachers say about you?Did you ever have extra support in school?Did you have a Statement of Special Educational Needs or an Education, Health and Care Plan (EHCP)?What is the highest educational qualification you hold?EmploymentAre you currently employed? If so what do you do?What previous roles have you worked in?Have you ever had difficulties in work? If so, please explain what these were / areHave you ever had difficulties finding employment? If so what were these?Δ
