Under 18s Autism Assessment Background Information Form Under 18 Autism Assessment Background Questionnaire Step 1 of 6 16% Personal InformationName of Person being assessed First Last First name you would like used throughout report Date of Birth DD slash MM slash YYYY School / Setting attended Name of person completing this form First Last Relationship to person being assessed Current ConcernsWhat are your main current concerns for your child?Has your child had any distressing life experiences such as the loss of a loved one, accident or other traumatic event? If so, please provide detailsWhat is your child’s sleep pattern like?Do you have concerns about your child safety? If so, what concerns do you have?Professional Involvement What, if any, professionals are currently involved with your child or has your child been referred to? (please list professional's name, role, service and if they are involved or referred). Family Background Who lives at home with your child?Please detail anyone whom your child has regular overnight stays withPlease 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 schizophrenia Medical History Does your child have any medical diagnosis? if so please list belowPlease list any medications that your child is prescribedDoes your child have any vision or hearing problems?Has a professional ever raised concerns about your child’s development?Has your child ever attempted to harm themselves or talked about wanting to harm themselves?Has your child ever sustained a head injury? DevelopmentWere there any issues with pregnancy?Were there any complications during birth?At how many weeks was your child born and what did they weigh at birth?Were there any concerns during the first 6 weeks?What were they like as a baby?At what age did they first walk unaided?At what age did they say their first meaningful words?At what age did they say their first phrases?Did your child ever lose language or other skills after gaining them?At what age was your child dry by day?At what age were they dry by night?At what age did you first have concerns about your child’s development? Education Please list all education settings name and dates attended (including pre-school)Education SettingsHow did your child first settle into school or nursery?How do they feel about school now?What do their teachers report about them?Do you have concerns about your child in school?Has your child ever had SEN support in school?Does your child have an Education, Health and Care Plan (EHCP)? Δ
