autism pathway pre- assessment questionnaire

ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN

Relationship status Please tick:SingleMarriedDivorcedSeparatedWidowedLiving with partnerIn relationship but not living togetherPrefer not to answer

Autism pathway pre-assessment questionnaire

Please complete this questionnaire and return it to us before your initial appointment in the stamped addressed envelope provided. Providing this information will help us to know more about you and reduce the amount of questions we need to ask during your appointment. Please note all information is strictly confidential.

Instructions for completing the questionnaire

Please tick any YES/NO questions and answer all questions, providing additional details where necessary. If you are unable to complete the questionnaire, or would like a member of the team to support you, please contact us on 01924 316490 and we will be happy to help.

Contact information

Name

Address

Daytime telephone number

Mobile telephone number

Email address

Please provide the name of your next of kin

Contact telephone number/address of your next of kin

Your personal information

Date of birth

Place of birth

Current relationship status


Are you in agreement for your carer to be contacted and involved in your care from our service?

Yes No

Please give the details of everyone living with you/at your address

Current accommodation status

Accommodation status Please tick:Living aloneLiving with partnerLiving with parentsSheltered/temporary accommodationNo fixed addressOther (please specify):

Do you have a carer? Yes No

If yes, name and address of your carer

Name Gender Date of birth Relationship to you (eg. wife, daughter, adopt-ed son etc.)

Details of any mental health/physical health/other diagnoses


Disability Living Allowance/PIP

Employment Support Allowance

Housing Benefit

Other (please give details)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Have you ever been investigated by the Police or charged with a criminal offence? (e.g. cautions/convictions/court appearances/imprisonment)

Are you currently receiving any of the following benefits?

If yes, please give further details including charges and dates:

What type of school did you attend?

Have you ever received a Statement of Special Educational Needs (SEN) or had an Educational Health Care Plan (EHCP) during your education?

Education

School type Please tick:Mainstream state schoolMainstream private schoolSchool for children with behavioural and/or emotional difficultiesSpecialist school for children with autismSchool for children with severe learning disabilitiesSchool for children with moderate learning disabilitiesSchool for children with physical disabilities and/or sensory impairmentsLanguage unit within a schoolOther (please specify):


Please state your highest level of qualification to date:

Qualification Please tick:O level/CSE/GCSEAS LevelA LevelBTEC or equivalentNVQHigher National DiplomaFirst degree or equivalent professional qualificationHigher degree (e.g. Masters, PhD)Other (please give details):

Employment

Are you currently in paid employment?

Please give a brief list of your past employment to date and why you left:

Yes No

Dates (year) Company Job title Type of work Why you left


Family structure

Please complete the following information about your mother:

Name

Is she: Living Deceased

Age

Occupation

Has your mother ever been diagnosed with a mental health condition or other diagnosis?

Please complete the following information about your (birth) father:

Name

Is he: Living Deceased

Age

Occupation

Has your father ever been diagnosed with a mental health condition or other diagnosis?

If yes, please could you give us some details?


Has your mother ever been diagnosed with any physical health conditions?

Has your father ever been diagnosed with any physical health conditions?



Yes No

Yes No

Yes No

Yes No


Do you have any children who do not live with you?

Do you have any brothers or sisters?

If yes, please complete the following information for each of your children.

If yes, please complete the following information for each of your siblings.

Yes No

Yes No

Name Gender Date of birth Living or deceased


Name Gender Date of birth Living or deceased



Please could you give information about any other family details you think may be relevant? (e.g. stepchildren, previous marriages, adoptions, foster care, other family members such as grandparents who may have a mental health condition):

Please give details of any allergies and the current medication you have been prescribed for either mental health and/or physical health reasons. Please include name, dosage and what it is prescribed for.

Name and address of your GP

Do you:

Medical history

Allergies:

Allergic to:

What happens when exposed

Smoke cigarettes/tobacco?

If yes, how many cigarettes do you smoke a day?

Smoke cannabis?

If yes, how much cannabis do you smoke each day? (e.g. number of joints, ounces of cannabis)

Current medication

Yes No

Yes No

1-5 5-10 10-15 15-20 20+


Do you have any diagnosed physical health conditions?

Have you ever felt suicidal?

If yes, have you ever planned or attempted suicide?

If yes, please give some details:

Have you ever been diagnosed with the following?

If yes, please give details:

Autism spectrum disorder (including Asperger’s)

Tourette’s syndrome

Obsessive compulsive disorder (OCD)

(General) Anxiety disorder

Depression

Dyspraxia

Dyslexia

Dyscalculia

Learning disability or global developmental delay

Any genetic disorder

Sleep disorder

Visual problems

Hearing problems

Language delay or other language disorders

Schizophrenia

Bipolar disorder

Personality disorder

Substance misuse

Any other mental health condition

If yes, please give details:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


Have you ever been referred to any other of the following professionals?

Please give the names and addresses of any other clinicians or services you have seen (either in the past or currently for mental health or social care reasons (including social workers, probation officers, etc.):

Psychiatrist

Clinical psychologist

Educational psychologist

Forensic psychologist

Nurse

Speech and language therapist

Occupational therapist

Social worker

Probation officer

Support worker

Disability employment advisor

Other (give details)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Name Profession/service Date seen Current or past involvement


Health and wellbeing screening

Health

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Please mark your answer with a tick)

If you ticked any of the problems above, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Problem Not at all

Several days

More than half the days

Nearly every day

1 Little interest or pleasure in doing things2 Feeling down, depressed, or hopeless3 Trouble falling or staying asleep, or sleeping too

much4 Feeling tired or having little energy5 Poor appetite or overeating6 Feeling bad about yourself – or that you are a

failure or have let yourself or your family down7 Trouble concentrating on things, such as reading

the newspaper or watching television8 Moving or speaking so slowly that other people

could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

9 Thoughts that you would be better off dead, or of hurting yourself in some way

10 Feeling nervous, anxious or on edge11 Not being able to stop or control worrying12 Worrying too much about different things13 Trouble relaxing14 Being so restless that it is hard to sit still15 Becoming easily annoyed or irritable16 Feeling afraid as if something awful might hap-

pen

Not difficult at all Somewhat difficult Very difficult Extremely difficult


Mood

Please answer each question to the best of your ability. (Please mark your answer with a tick)

1. Has there ever been a period of time when YOU WERE NOT YOUR USUAL SELF and…

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?

Yes No

…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?…you were so irritable that you shouted at people or started fights or arguments?…you felt much more self-confident than usual?…you got much less sleep than usual and found you didn’t really miss it?…you were much more talkative or spoke much faster than usual?…thoughts raced through your head or you couldn’t slow your mind down?…you were so easily distracted by things around you that you had trouble concentrating or staying on track?…you had much more energy than usual?…you were much more active or did many more things than usual?…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?…you were much more interested in sex than usual?…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?…spending money got you or your family into trouble?

Yes No

4. Have any of your blood relatives (i.e. children, siblings, parents, grand-parents, aunts, uncles) had manic-depressive illness or bipolar disorder?

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Yes No

2. If you ticked YES to more than one of the above, have several of these ever happened during the same period of time?

No problem Minor problem Moderate problem Severe problem


Alcohol

(please tick the answer that is correct for you)

1. How often do you have a drink containing alcohol?

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

3. How often do you have six or more drinks on one occasion?

4. How often during the last year have you found it difficult to get the thought of alcohol out of your mind?

5. How often during the last year have you found that you were not able to stop drinking once you had started?

6. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

7. How often during the last year have you needed an alcoholic first drink in the morning to get yourself going after a heavy drinking session?

8. How often during the last year have you had a feeling of guilt or remorse after drinking?

9. Have you or someone else been injured as a result of your drinking?

10. Has a relative, friend, doctor or any other health worker been concerned about your drinking or suggested you cut down?

Never Monthly 2-4 times a month 2-3 times a week 4 or more times a week

Never Less than monthly Monthly Weekly Daily or almost daily






No Yes, but not in the last year Yes, during the last year

No Yes, but not in the last year Yes, during the last year

1 or 2 3 or 4 5 or 6 7 to 9 10 or more


Drugs

These questions refer to the past 12 months (please mark your answer with a tick)

Brain injury (please mark your answer with a tick)

Yes No

1. Have you used drugs other than those required for medical reasons?2. Do you abuse more than one drug at a time? 3. Are you always able to stop using drugs when you want to? 4. Have you had “blackouts” or “flashbacks” as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your wife/husband (or parent) ever complain about your involve-ment with drugs?7. Have you neglected your family because of your use of drugs? 8. Have you done anything illegal in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?10. Have you had medical problems as a result of your drug use (for exam-ple: memory loss, liver problems, fits, bleeding)?

Yes No

1. Have you ever hit your head or been hit on the head?2. Were you ever seen in A&E, hospital, or by a doctor because of an injury to your head?3.a. Did you ever lose consciousness or experience a period of being dazed and confused because of an injury to your head?

3.b. If YES, have you experienced any of these problems in your daily life since you hit your head? Tick whichever applies to you:

Headaches

Dizziness

Anxiety

Depression

Difficulty concentrating

Difficulty remembering

Difficulty reading

Difficulty writing

Difficulty calculating

Poor problem solving

Difficulty performing your job

Change in relationships with others

Poor judgement (being fired from job, arrests, fights)

4. Any significant sicknesses?


Personality (please mark your answer with a tick)

Yes No

1.a. Some people find their mood changes frequently - as if they spend every day on an emotional roller coaster. For example, they might switch from feeling angry to depressed to anxious many times a day. Does this sound like you?

1.b. If YES, have you been this way most of your life?2.a. Some people prefer to be the centre of attention, while others are content to remain on the edge of things. Would you describe yourself as preferring to be the centre of attention?

2.b. If YES, does it bother you when someone else is in the spotlight?

3.a. Do you frequently insist on having what you want right now, even when waiting a little longer would get you something much better?

3.b. Do you often get in trouble at work or with friends because you act excited at first but then lose interest in projects and don't follow through?

4. Do you find that most people will take advantage of you if you let them know too much about you?

5.a. Do you generally feel nervous or anxious around people?

5.b. Do you avoid situations where you have to meet new people?

6.a. Do you avoid getting to know people because you're worried they may not like you?

6.b. If YES, has this affected the number of friends that you have?

7.a. Do you keep changing the way you present yourself to people because you don’t know who you really are?

7.b. Do you often feel like your beliefs change so much that you don't know what you really believe any more?

8. Do you often get angry or irritated because people don't recognize your special talents or achievements as much as they should?9.a. Do you often suspect that people you know may be trying to cheat or take advantage of you?

9.b. If YES, do you worry about this a lot?10. Do you tend to hold grudges or give people the silent treatment for days at a time?11.a. Do you get annoyed when friends or family complain about their problems?11.b. Do people complain that you're not very sympathetic to their prob-lems?


Autism screening

Empathy quotientBelow is a list of statements. Please read each statement carefully and rate how strongly you agree or disagree with it by selecting a square with your answer. There are no right or wrong answers, or trick questions.

Statement Stronglyagree

Slightlyagree

Slightlydisagree

Stronglydisagree

1 I can easily tell if someone else wants to enter a conversation.

2 I prefer animals to humans.3 I try to keep up with the current trends and

fashions.4 I find it difficult to explain to others things that I

understand easily, when they don’t understand it for the first time.

5 I dream most nights.6 I really enjoy caring for other people7 I try to solve my own problems rather than

discussing them with others.8 I find it hard to know what to do in a social

situation.9 I am at my best first thing in the morning.10 People often tell me that I went too far in driv-

ing my point home in a discussion.11 It doesn’t bother me too much if I am late meet-

ing a friend.12 Friendships and relationships are just too diffi-

cult, so I tend not to bother with them.13 I would never break a law, no matter how

minor. 14 I often find it difficult to judge if something is

rude or polite.15 In a conversation, I tend to focus on my own

thoughts rather than on what my listener might be thinking.

16 I prefer practical jokes to verbal humor.17. I live life for today rather than the future.18. When I was a child, I enjoyed cutting up worms

to see what would happen.19. I can pick up quickly if someone says one thing

but means another.20. I tend to have very strong opinions about moral-

ity.21. It is hard for me to see why some things upset

people so much.22. I find it easy to put myself in somebody else’s

shoes.23. I think that good manners are the most impor-

tant thing a parent can teach their child.24. I like to do things on the spur of the moment.


25. I am good at predicting how someone will feel.26. I am quick to spot when someone in a group is

feeling awkward or uncomfortable.27. If I say something that someone else is offended

by, I think that that’s their problem, not mine.28. If anyone asked me if I liked their haircut, I

would reply truthfully, even if I didn’t like it.29. I can’t always see why someone should have felt

offended by a remark.30. People often tell me that I am very unpredicta-

ble.31. I enjoy being the centre of attention at any so-

cial gathering.32. Seeing people cry doesn’t really upset me.33. I enjoy having discussions about politics. 34. I am very blunt, which some people take to be

rudeness, even though this is unintentional.35. I don’t find social situations confusing.36. Other people tell me I am good at understand-

ing how they are feeling and what they are thinking.

37. When I talk to people, I tend to talk about their experiences rather than my own.

38. It upsets me to see an animal in pain.39. I am able to make decisions without being influ-

enced by people’s feelings.40. I can’t relax until I have done everything I had

planned to do that day.41. I can easily tell if someone else is interested or

bored with what I am saying.42. I get upset if I see people suffering on news pro-

grams.43. Friends usually talk to me about their problems

as they say that I am very understanding.44. I can sense if I am intruding, even if the other

person doesn’t tell me.45. I often start new hobbies, but quickly become

bored with them and move on to something else.

46. People sometimes tell me that I have gone too far with teasing.

47. I would be too nervous to go on a big roller-coaster.

48. Other people often say that I am insensitive, though I don’t always see why.

49. If I see a stranger in a group, I think that it is up to them to make an effort to join in.

50. I usually stay emotionally detached when watch-ing a film.


Slightlyagree

Slightlydisagree

Stronglydisagree


55. I can tell if someone is masking their true emo-tions.

56. Before making a decision, I always weigh up the pros and cons.

57. I don’t consciously work out the rules of social situations.

58. I am good at predicting what someone will do.59. I tend to get emotionally involved with a friend’s

problems.60. I can usually appreciate the other person’s view-

point, even if I don’t agree with it.


Slightlyagree

Slightlydisagree

Stronglydisagree

51. I like to be very organised in day to day life and often make lists of the chores I have to do.

52. I can tune into how someone else feels rapidly and intuitively.

53. I don’t like to take risks.54. I can easily work out what another person might

want to talk about.

Statement Definitelyagree

Slightlyagree

Slightlydisagree

Definitelydisagree

1. I prefer to do things with others rather than on my own.

2. I prefer to do things the same way over and over again.

3. If I try to imagine something, I find it very easy to create a picture in my mind.

4. I frequently get so strongly absorbed in one thing that I lose sight of other things.

5. I often notice small sounds when others do not.6. I usually notice car number plates or similar

strings of information.7. Other people frequently tell me that what I’ve

said is impolite, even though I think it is polite.8. When I’m reading a story, I can easily imagine

what the characters might look like.9. I am fascinated by dates.10. In a social group, I can easily keep track of sever-

al different people’s conversations.11. I find social situations easy.12. I tend to notice details that others do not.13. I would rather go to a library than a party.14. I find making up stories easy.

The adult autism spectrum quotient Below is a list of statements. Please read each statement very carefully and rate how strongly you agree or disagree with it by by selecting a square with your answer.DO NOT MISS ANY STATEMENT OUT.


15. I find myself drawn more strongly to people than to things.

16. I tend to have very strong interests which I get upset about if I can’t pursue.

17. I enjoy social chit-chat.18. When I talk, it isn’t always easy for others to get

a word in edgeways.19. I am fascinated by numbers.20. When I’m reading a story, I find it difficult to

work out the characters’ intentions.21. I don’t particularly enjoy reading fiction.22. I find it hard to make new friends.23. I notice patterns in things all the time.24. I would rather go to the theatre than a museum.25. It does not upset me if my daily routine is dis-

turbed.26. I frequently find that I don’t know how to keep

a conversation going.27. I find it easy to “read between the lines” when

someone is talking to me.28. I usually concentrate more on the whole picture,

rather than the small details.29. I am not very good at remembering phone num-

bers.30. I don’t usually notice small changes in a situa-

tion, or a person’s appearance.31. I know how to tell if someone listening to me is

getting bored.32. I find it easy to do more than one thing at once.33. When I talk on the phone, I’m not sure when it’s

my turn to speak.34. I enjoy doing things spontaneously.35. I am often the last to understand the point of a

joke.36. I find it easy to work out what someone is think-

ing or feeling just by looking at their face.37. If there is an interruption, I can switch back to

what I was doing very quickly. 38. I am good at social chit-chat.39. People often tell me that I keep going on and on

about the same thing.40. When I was young, I used to enjoy playing

games involving pretending with other children.41. I like to collect information about categories of

things (e.g. types of car, types of bird, types of train, types of plant, etc.).

Statement Definitelyagree

Slightlyagree

Slightlydisagree

Definitelydisagree


42. I find it difficult to imagine what it would be like to be someone else.

43. I like to plan any activities I participate in care-fully.

44. I enjoy social occasions.45. I find it difficult to work out people’s intentions.46. New situations make me anxious.47. I enjoy meeting new people.48. I am a good diplomat.49. I am not very good at remembering people’s

date of birth.50. I find it very easy to play games with children

that involve pretending.

Developed by:The Autism Research CentreUniversity of Cambridge

S. Baron-Cohen, S. Wheelwright, R. Skinner, J. Martin and E. Clubley, (2001)The Autism Spectrum Quotient (AQ) : Evidence from Asperger Syndrome/High Functioning Au-tism, Males and Females, Scientists and MathematiciansJournal of Autism and Developmental Disorders 31:5-17©MRC-SBC/SJW Feb 1998


Statement Never Rarely Some-times

Often Very often

1 How often do you have difficulty con-centrating on what people are saying to you even when they are speaking to you directly?

2 How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

3 How often do you have difficulty un-winding and relaxing when you have time to yourself?

4 When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them them-selves?

5 How often do you put things off until the last minute?

6 How often do you depend on others to keep your life in order and attend to details?

ADHD screeningPlease answer the questions below, rating yourself on each of the criteria shown using the scale below. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months.


Your initial appointment with us

Please let us know who will be coming with you to your appointment. Please note, because we are required to take a full developmental history in order to make an accurate diagnosis, it is very important that where possible you have someone with you who knew you well as a child. If you think you may have difficulties with this, please contact the service on 01924 316490.

Name(s)

Are they your mother/father/other (please specify)?

Please find a questionnaire enclosed for you to ask someone who knew you as a child to complete.

Confidentiality

Anything that is written about a patient or relative is kept strictly confidential and is normally only seen by people working in the service. However, as part of our day-to-day duties as clinicians, we are required to record patient notes on an NHS electronic notes system. This system is protected by the Data Protection Act, and access is monitored and limited to only those clinicians directly involved in the patient’s care.

We normally send copies of assessment reports to the referrer and your GP. If you would like yourself or someone else to receive a copy of the report please let us know at one of your appointments or by contacting us in writing.

Members of staff carry out research and also audit their work. Occasionally, clinicians may wish to write up details of any treatments or cases for publication. We will always seek the patients’ written consent before this happens. In such cases where material is agreed for publication, all patient data is completed anonymised and non-identifiable. As part of our work we also receive regular clinical supervision which means that we will discuss the patient’s case with a qualified colleague. We also have regular team meetings at the clinic to discuss the progress of cases within the service. In all such cases, members of staff are bound by patient confidentiality agreements unless we identify that there is a concern or risk to either the patient or someone else. We will always seek to discuss this with the patient in the first instance.

Do you consent for your data to be used for research purposes:

Thank you for taking the time to complete this questionnaire. Please check you have answered all questions before returning it to us.

Yes No

JOB NO 1455 FEB 20

autism pathway pre- assessment questionnaire

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