Physical Address: 1600 7th Avenue South, Clinic 7 Birmingham, AL 35233 Phone: 205-638-5277 Fax: 205-212-2997

Mailing Address: Medical Autism Clinic McWane Bldg Dearth Tower Ste 5602 1600 7th Ave South Birmingham, AL 35233

Dear Parent/Guardian: We are sending you an Intake Form to complete based on a request by one of your child’s health care providers to conduct a comprehensive evaluation of your child. The Intake Form must be completed and returned to our office to begin the evaluation process and schedule appointments. Appointments cannot be confirmed until this information is received. Please use the checklist below before returning the Intake Form to ensure that we have all the information we need to schedule the appropriate appointments for your child. _____ Complete all relevant questions on the Intake Form. Please pay special attention to page 8 which

requests information about other providers that have cared for or evaluated your child. Provide us as much of the information requested about these providers as possible so that, with your permission, we can contact them about your child.

_____ Be sure to complete and sign the Insurance information/authorization of the Intake Questionnaire. _____ Be sure to complete and sign the Non-Covered Services Waiver. _____ If you have copies of any recent evaluations (psychological, development testing, speech/language,

hearing, vision) please include them when you mail us your Intake Form. _____ If your child is between the ages of 2 and 10 years old and is receiving special services at school, please

include any copies of their IEP or the results of any testing the school conducted if you have that information available to you.

_____ If you are the child’s guardian and not the birth or adoptive parent please include copies of the

Guardianship papers (court order or Power of Attorney) with your Intake Form. If you need assistance in completing the Intake Form, please call (205) 638-5277 and we will assist you with your questions. We look forward to working with you and your family. Upon receipt of the above information, you can expect to hear from our office within a few weeks. If you do not hear from us, please call to make sure we have received this information. Please mail or fax packet to the mailing address or fax number listed below.

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MEDICAL AUTISM CLINIC AT THE CHILDREN’S HOSPITAL OF ALABAMA rev 9-15 PARENT QUESTIONNAIRE Chart #________________ (For office use only)

DEMOGRAPHIC INFORMATION: Date Completed: _________________ Child’s Name: ___________________________________________________________________________________________________________ Last First Middle Nickname Birth Date: ___________________ Age: __________ Gender: Male Female Race: ____________ Address: __________________________________________________________ Home Phone: __________________________________________ __________________________________________________________________ Second Phone: _________________________________________ City State Zip County Name of person completing form: ______________________________________ Relationship to child: ________Email__________________________ ________________________________________________________________________________________________________________________ Relative or friend for emergency contact Relationship Primary phone Additional Phone Referred to this clinic by: __________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Address City State Phone

Reason(s) for requesting evaluation: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What concerns would you like us to address during your visit? Feeding Problems Sleep Problems Motor Problems Possible genetic problem Sensory Problems Hearing Vision Severe behavioral problems

Speech/language/social

Has your child ever been given a diagnosis of Autism, PDD NOS or Asperger’s Disorder? If so, what was the diagnosis and who made the diagnosis and when? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY PRENATAL HISTORY: Were fertility medications or treatments used for this pregnancy? Yes No If yes, what type? _________________________________________________________________________________________________________

Singleton pregnancy Twin pregnancy Other: ____________________

Mother’s age (at time of child’s birth) ________ yrs. Father’s age (at time of child’s birth) ________ yrs.

Number of pregnancies: _______ Number of miscarriages: _______ Stillbirths? _______

Were any substances used during pregnancy? (e.g., alcohol, tobacco, drugs) Yes No If so, please specify: ______________________________________________________________________________________________________

Did mother take Pre-natal Vitamins during her pregnancy? Yes No any medications? Yes No Please describe: __________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Were there any problems experienced during pregnancy with this child? Yes No If yes, please explain: _____________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

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BIRTH HISTORY Hospital where child was born:_______________________________________________________________________________________________ If baby was transferred to another hospital please name hospital: ___________________________________________________________________ Birth weight: Pounds _________ Ounces _________ Length _________ Head circumference _________ What was the baby’s gestational age? (if known)_______ Was the baby average for gestational age (AGA) small for gestational age (SGA) large for gestational age (LGA)

Was the baby born at: term (37-42 weeks); preterm (36 weeks or less gestation); post-term (greater than 42 weeks gestation)

Was this a Vaginal Delivery or Cesarean Section? VD C-section Was delivery induced (medication given to start labor)? Yes No If no, were meds given to help delivery progress (augmentation)? No Yes Length of Labor (time in active labor): _____________ hours N/A

Presentation: Vertex or head first Breech Other Did baby require resuscitation (CPR, intubation and ventilation, medications) at birth? No Yes Apgar scores: _______ at 1 min, _______ at 5 min, do not know normal abnormal/low If your baby experienced difficulties during labor or delivery, please describe: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Did baby go to the intensive care nursery? Yes No If baby was in the intensive care nursery, for how long? __________________________________________________________________________ And why? _______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ INFANCY Did the baby have colic or significant irritability? No Yes How old was the baby when he/she first started sleeping more at night than during the day? _________________ Were there any feeding problems during infancy? No Yes Was the child noted to be either floppy or stiff as infant? Floppy Stiff Normal Please describe any problems: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________ MEDICAL/SURGICAL HISTORY Has the child had any serious Illnesses or other Health problems (Other Than Colds): No Yes (if yes list below) Type How Often Approximate Date ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If the child is currently taking medications, please list below: Type of Medication Dose Reason ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Has the child had any hospitalizations: No Yes (if yes list below) Date Hospital name and location Reason ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the child had any serious Accidents or Injuries: No Yes (if yes list below) Date Type ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has the child had any Surgeries: No Yes (if yes list below) Date Type Hospital name and location Reason ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Does the child have any Drug or medication Allergies? No Yes (explain): _________________________________________ Food Allergies? No Yes (explain): _________________________________________________________________ Environmental Allergies? No Yes (explain): _________________________________________________________________ Are the child’s immunizations up to date? Yes No (explain) _________________________________________________________________

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________________________________________________________________________________________________________________________ Current Pediatrician (PCP) Address Phone

Names of other Medical Providers/Specialists: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Has your child ever had genetic testing? No Yes (if which tests?) _________________________________________________________ Has your child ever had an MRI? No Yes (explain) _______________________________________________________________ Has your child ever had a CT Scan? No Yes (explain) _______________________________________________________________ Has your child had other procedures or medical tests? No Yes (explain) ______________________________________________________ ________________________________________________________________________________________________________________________ REVIEW OF SYMPTOMS: Circle or check mark any past or current problems (if yes, please explain)

Eyes/Vision problems _______________________________________________________

Ear, Nose, or Throat problems (recurrent ear infections) _______________________________________________________

Stomach or intestinal problems _______________________________________________________

Stomach or intestinal problems _______________________________________________________

Growth/weight problems _______________________________________________________

Kidney problems _______________________________________________________

Heart or blood pressure problems _______________________________________________________

Blood Abnormalities (anemia, leukemia, etc) _______________________________________________________

Respiratory problems (asthma, sleep issues, snoring) _______________________________________________________

Other not listed: _______________________________________________________

Seizures

_______________________________________________________ Other neurological problems (Shunts, bleed, stroke, meningitis)

_______________________________________________________ Skin problems (rashes, acne, eczema, etc)

______________________________________________________ Liver, pancreas, or digestive

_______________________________________________________ Thyroid problems, Diabetes

_______________________________________________________ Other Endocrine Problems

_______________________________________________________ Musculoskeletal (joints or bone) problems

_______________________________________________________ Psychiatric problems (depression, bipolar, etc)

_______________________________________________________

Hearing: (If your answer is yes, please explain) Did your child pass their newborn hearing screening in both ears? No Yes Has your child had their hearing tested since birth? No Yes What were the results? ___________________________________________ Date and Location of last hearing test ________________________________________________________________________________________ Is there any family history of childhood hearing loss? No Yes ________________________________________________________________ Sleep: Does the child have any difficulties around sleeping? No Yes (check the following that apply)

Sleeps with parents Nightmares Sleeps in own bed Night Terrors Maladaptive behaviors around going to bed (reluctance or avoidance) Problems with sleep onset (falling asleep) Problems with sleep maintenance (staying asleep) Problems with early wakening Other: _______________________________________________ On an average, how many hours per day does your child sleep? __________

Appetite is _____________________________. Does he/she have any significant food preferences/dislikes (marked food selectivity)? No Yes If food selective, please describe

Texture selective Temperature selective Color selective Very limited variety of foods: ___________________

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FAMILY INFORMATION:

Child’s Legal Guardian: Marital Status of Birth Parents: Both Birth Parents Birth Father Not Married Divorced Birth Mother Adoptive Parents Married Father remarried Department of Human Resources Separated Mother remarried Other (Please explain)____________________

If Birth parents are not legal guardian (s), please indicate with whom child lives: _______________________________________________________ Birth Mother’s Name: ___________________________________________________________ Age: ______ Education (highest grade): ______ Place of Employment: ____________________________________________________________ Telephone: ______________________________ Medical Problems: ________________________________________________________________________________________________________ Academic/Learning Problems: _______________________________________________________________________________________________ Birth Father’s Name: ____________________________________________________________ Age: ______ Education (highest grade): ______ Place of Employment: ____________________________________________________________ Telephone: _______________________________ Medical Problems: ________________________________________________________________________________________________________ Academic/Learning Problems: _______________________________________________________________________________________________

Brothers and Sisters: (Please include and indicate half-brothers/sister). For additional siblings add on separate piece of paper. Name

Age

How related (maternal ½ sib; paternal ½ sib; full

brother or sister)

Grade

Medical Problems

Behavior Problems

Academic or Developmental

Problems

Is there family history on either side of the child’s family (extended family) of any of the following conditions? Condition

Father’s Side Yes Who (dad’s mom, dad, etc)? Describe

Problem

Mother’s Side Yes Who (mom’s mom, dad, etc)? Describe

Problem Autism/ Asperger’s Disorder/ PDD NOS Developmental delay Learning Problems Mental Retardation/Cognitive Impairment Hyperactivity Attention Deficit (ADD or ADHD) Speech or language problem(s) Tics or other movements Epilepsy (seizures) Severe emotional problem(s) (e.g., depression, schizophrenia, bipolar disorder, etc)

Alcohol/drug problem(s) Stillbirths Birth defect(s) Congenital heart problems Diabetes Thyroid problem(s) Hearing loss/problem(s) Other: (describe)

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DEVELOPMENTAL HISTORY Caregiver became concerned about: Social Interaction at age ___________________ Language at age ___________________ Cognitive/Intellectual at age __________________ Behavioral at age __________________ Did your child lose abilities (regress)? No Yes (explain) __________________________________ Please fill age when the child attained the skill, if you do not know the age just use “early”, “late”, “on time” or “not yet” Gross Motor Skills: Roll over ______________ Sit alone (unsupported) ______________ Crawl ______________ Walk ______________ Run ______________ Does your child walk on their toes? No Yes Does your child have balance problems: No Yes

Does your child: Climb Stairs No Yes Ride a bicycle/tricycle No Yes Play Sports No Yes

Comments: ____________________________________________________________________________ Fine Motor Skills: Transfers objects between hands ____________ Turns paper pages in a book ____________ Develop Right or Left-handedness? __________ Right Handed Left Handed Can’t tell

If your child has difficulty with coloring, fastening or handwriting please explain: __________________________________________________ ________________________________________________________________________________________________________________________ Speech Language At what age did your child first smile? ________________________

Your child communicates by which of the following (check all that apply) Crying Sentences Playful Sounds Sign language Words Eye pointing Electronic talking devices Picture Communication Boards/Schedules Phrases Pointing with index finger

How much of your child’s speech is understandable to you? Some Most All How much of your child’s speech is understandable to others? Some Most All

Please give an example of words/phrases/sentences your child typically uses to communicate: ________________________________________ ________________________________________________________________________________________________________________________

Does the child have any problems: Understanding what someone says No Yes (explain)____________________________________________________________________ Talking No Yes (explain)____________________________________________________________________

Feeding: Does the child have any feeding difficulties? Yes No Does he or she feed self? Yes No If no, who feeds him/her? _____________________________________

Prefers to use fingers Uses: Scoops with spoon Spreads with knife Spears with fork Sippy cup open-top cup straw Current weight_________

What special diets or dietary supplements does the child take? None CF/GF diet He/she takes the following vitamins/supplements: _______________________________________________________________

Toileting: Not Toilet Trained At what age was child urine / bladder trained? ______________. At what age was child bowel trained? ______________. Were there/are there any problems? _______________________________________________________________________________ Dressing / Self-Help Please check all that apply for this child:

Does not assist with dressing Helps with dressing Helps with undressing Undresses completely Dresses completely Buttons Ties Shoes Brush teeth / rinse mouth Brush /comb hair Prepare meal Use Microwave

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BEHAVIOR/EMOTIONAL CONCERNS: Please check any of the following behaviors that you feel your child has and their frequency. Please make comments to the side:

Displays Aggressiveness No Sometimes Often Temper Tantrums No Sometimes Often Acts Out No Sometimes Often Has Poor Organizational Skills No Sometimes Often Difficulty following direction No Sometimes Often Mood Swings No Sometimes Often Day Dreams No Sometimes Often Cries Easily No Sometimes Often Difficulty changing routine No Sometimes Often Repetitive behaviors No Sometimes Often Acts without thinking No Sometimes Often Conduct problems No Sometimes Often Fails to complete tasks No Sometimes Often Fails to follow instructions No Sometimes Often Loses things No Sometimes Often Easily distracted No Sometimes Often Forgetful No Sometimes Often Out of seat No Sometimes Often Fidgety No Sometimes Often Runs and climbs excessively No Sometimes Often Very loud No Sometimes Often Always on the go No Sometimes Often Talks excessively No Sometimes Often Excessive crying No Sometimes Often Self injury No Sometimes Often Food refusal No Sometimes Often Head-Banging No Sometimes Often Poor eye contact No Sometimes Often Difficult transitions No Sometimes Often Hand flapping/finger flicking No Sometimes Often Sound Anxiety No Sometimes Often Separation Anxiety No Sometimes Often

Other:

Types of Discipline Used: Time-out Spanking / Physical Punishment Withdraw Privileges 1, 2, 3 Counting Reprimand Other: _______________________________________________________________________________________________________________

Discipline is generally effective ineffective

Other parental concerns about child’s behavior: _________________________________________________________________________________ _______________________________________________________________________________________________________________________ Does your child prefer to play (mark any that applies):

Alone With all ages With same children With younger children With older children With other children (specify) _____________________________________________________________________________________________

Do you have any concerns about your child’s social skills or play skills? Yes No If yes, please explain: _____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ What does child enjoy doing in his/her spare time? ______________________________________________________________________________ In your opinion how old does your child act? ___________________________________________________________________________________ Child’s best ability: _______________________________________________________________________________________________________ Skill with greatest difficulty: ________________________________________________________________________________________________

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EDUCATIONAL / SCHOOL HISTORY: *Please attach child’s Early Intervention IFSP or IEP or any previous psychological or school evaluations

Name of school & address: _________________________________________________________________________________________________ ____________________________________City _________________ State________ Zip Code ____________ School district where you live: ______________________________________________________________________________________________

Public School Private Home Schooled Current grade ________ Teacher’s name __________________________________________________________________________________ Grades repeated, if any: __________________ Does the child have an Individual Educational Plan (IEP)? No Yes If your child received Early Intervention, when was it started: ______________________

Type of classroom: Daycare Early Intervention Preschool Kindergarten Regular classroom Head Start Regular and special classes Special classes (Describe) _______________________________

What is his/her current academic performance like? _____________________________________________________________________________ _______________________________________________________________________________________________________________________ Please describe how your child gets along with other students at school: ______________________________________________________________ ________________________________________________________________________________________________________________________ Please describe any behavioral problems in the classroom: ________________________________________________________________________ ________________________________________________________________________________________________________________________ Please add any additional comments you would like to make: ______________________________________________________________________ ________________________________________________________________________________________________________________________ Does your child receive the following special services (check all that apply)?

Physical therapy Occupation therapy Speech/language therapy Adaptive P.E. Hearing impaired Vision impaired Resource room/special instruction Bus/transportation services Other, specify _________________________________________________________________________________________________________

If your child is not in school, please list any service(s) he/she is receiving Type Address How long ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ PREVIOUS EVALUATIONS/SERVICES: *Please attach copies of previous evaluations

List previous or most recent developmental or psychological evaluations that have been done on the child: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________

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BIRTH, TREATMENT, AND SCHOOL HISTORY SERVICES

Please complete any of the following pertaining to your child. It is very important that you furnish the complete address of each Agency/Provider you list.

Name __________________________________________________________________________________________________________________ If your child’s records are not under his/her current name, what should we request under? _________________________________________

Type of Service Provider

Agency/Provider Name Agency/Provider Address Date(s)Seen

Place of Birth:

Hospitalizations:

Hospitalizations:

Pediatrician:

Neurologist

Orthopedist

Geneticist

Eye Specialist

Hearing Specialist

Otorhinolaryngologist (ENT)

Psychiatrist

Psychologist

Nutritionist/Dietician

Occupational Therapist

Physical Therapist

Speech Language Therapist

Social Worker

Children’s Rehab. Services

Public Health Department

Dept. of Human Resources

Mental Health Center

Others, specify

Schools Attended Address Date (year) Attended

Evaluations may be required on separate days. Would you have transportation problems or other difficulties in keeping appointments? Yes No If yes, please explain. _____________________________________________________________________________________________________________________

UAB Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, McWane Bldg. Dearth Tower Ste. 5602 1600 7th Avenue South, Birmingham, Al 35233

tel. 205-638-5277 fax 205-212-2997 www.peds.uab.edu Clinic address: 1600 7th Avenue South, Clinic 7

Dear Parent, Speech Evaluation and Occupational Therapy Evaluations are an integral part of the Medical Autism Clinic protocol. Please sign and date the enclosed form and return to the address above so that we can proceed with processing your paperwork and scheduling an appointment in theMedical Autism Clinic. You may also fax the form to: Attention MAC at 205-212-2997. Please be aware that we are unable to schedule your child to be seen in our clinic until this form is returned. Please be aware also that should you decline Speech or OT services, we will be unable to see your child in the Medical Autism Clinic. Thank you, The MAC Team

Physical Address: Medical Autism Clinic 1600 7th Avenue South, Clinic 7 Birmingham, AL 35233 Phone: 205-638-5277 Fax: 205-212-2997

Mailing Address: Medical Autism Clinic McWane Bldg, Dearth Tower Ste. 5602 1600 7th Ave South Birmingham, AL 35233

Physical Therapy and Occupational Therapy Department Hearing and Speech Department

Non-Covered Services Waiver for Therapy Services Patient Name: ______________________________ MR# ___________________ _________________________ (Date of Service) I affirm that I have been informed of the costs and I understand that all or some of the services rendered may be considered non-covered by my insurance and therefore all costs are not allowable under my insurance. I hereby agree to accept full financial responsibility for all costs associated with the non-covered services received from Children’s of Alabama Hearing and Speech Department and PT/OT Department.

SERVICE DESCRIPTION AND CHARGE

Service Estimated Cost Please Circle Accept or Decline PT/OT Evaluation/Management Cost: $70 to $170 Accepts Services Declines Services Speech Evaluation/Management Cost: $84 to $313 Accepts Services Declines Services _______________________________________ _____________________ Beneficiary or Legal Guardian Signature Signature Date _______________________________________ ____________________ Witness Signature Date

PATIENT INFORMATION

Patient Name: First __________________________ Middle Initial______ Last_______________________________

Address_________________________________________City_________________State______Zip Code____________

Date Of Birth_________________________ Age ______ Sex Male Female Marital Status S M W D

Social Security #__________________________________Phone #____________________Work#__________________

Employer_______________________________ Employer’s Address__________________________________________

Friend or relative not living with you_______________________________________Phone#_______________________

RESPONSIBLE PARTY INFORMATION

Name First ________________________________Middle Initial _______Last__________________________________

Address___________________________________City_____________________State_______Zip Code_____________

Date of Birth _____________________________ Sex Male Female Social Security #_____________________

Relationship to Patient _______________________Home Telephone __________________Work #__________________

Employer ________________________________Employer Address__________________________________________

Friend or relative not living with you __________________________________________Phone #___________________

Email Address________________________________________________________________________________

INSURANCE INFORMATION

Primary Insurance___________________________________ Insurance Company ______________________________

Insurance Company Phone #___________________________ Insurance Address________________________________

Inured Name________________________________________ Relationship Self Spouse Dependent Other

ID# _____________________________ Group#__________________ Is this an employer group plan? Yes No

If yes, name of employer ______________________________Insured’s Employer_______________________________

Employer’s Address_____________________________________________Phone#______________________________

Insured Social Security # ______________________________ Date of birth_________________ Sex Male Female

Secondary Insurance Company_________________________________________ Phone#_________________________

Insurance Address____________________________________ ID# __________________Group#___________________

InsuredName_______________________________________RelationshipSelfSpouseDependentOther

Isthisanemployergroupplan?YesNoIfyes,NameofEmployer___________________________________

Insured’sEmployer____________________________Address_____________________________Phone#___________

InsuredSocialSecurity#______________________________Dateofbirth_________________SexMaleFemale

PLEASE RETURN TO: CHILDREN’S MEDICAL AUTISM CLINIC

Children’s Health-System-Authorization for Release of Information Patient Name (First, Last, MI):_________________________________________________________________

Address:__________________________________________________________________________________

Phone Number: (_____)____________________________Date of Birth:_______________________________

This Authorization applies to the following Information:

X All Information. I understand that the information may contain psychiatric/psychological, alcohol/drug abuse, and/or HIV

information and I expressly consent to the release of the information. Only the following records or types of Information: __________________________________________

_________________________________________________________________________________________

Treatment Dates: from (month/day/year) ______/______/______ to (month/day/year) ______/______/______ The Information may be released as follows:

by to (Please check all that apply)

X X Children’s Health System (Please provide address & phone number): Children’s of Alabama Medical

Autism Clinic, 1600 7th Avenue South, Dearth Tower Ste. 5602 Birmingham, AL 35233 (205) 638-5277

External Individual/Agency/Organization (Please provide address & phone number):________________

_________________________________________________________________________________________

Purpose of the release: X Continuity of Treatment Other (Please specify):__________________________________________

I understand the Information released will be limited to information necessary to fulfill the need or purpose

for the disclosure. If I have authorized the disclosure of Information to a recipient who is not subject to the

Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), then the recipient may re-disclose it

and it may no longer be protected under HIPAA, a federal privacy law. This Authorization is valid for ninety

(90) days from the date of signature, unless otherwise noted. This Authorization only applies to treatment

occurring before the date of signature. I may decline to sign this Authorization. I understand I may revoke

this authorization in writing at any time by completing a form available from Medical Information Services. If

I revoke this authorization, the revocation will not apply to information that has already been released in

response to this authorization. I understand the patient’s health care and the payment for the patient’s

health care will not be affected if I do not sign this form. I understand I may see and copy the Information

described on this form if I ask for it, and I may receive a copy of this form after I sign it. Before requesting

medical record copies, please about the copy fee by law that may apply. I represent that I have the authority

to and voluntarily grant permission for the Information to be released as described above.

Print name hereêêê Sign name here êêê

________________________________ __ ____________________________________ Patient/Parent/Legal Guardian Printed Name Patient/Legal Guardian Signature Date

Witness Signature hereêêê

_________________________________________ ____________________________________________

Patient Signature (if 14 or older) Date Witness Signature Date

UAB Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, McWane Bldg Dearth Tower Ste. 5602

1600 7th Avenue South, Birmingham, Al 35233 tel. 205-638-5277 fax 205-212-2997 www.peds.uab.edu Clinic address: 1600 7th Avenue South, Clinic 7

MEDICAL AUTISM CLINIC (MAC) Once you have received your appointment time, please arrive 30 minutes prior to your appointment time to check in. If you cannot keep this appointment, please call the office to reschedule. Our office number is 205-638-5277 Appointments can take several hours so please be prepared for this by bringing snacks or other items that can make the wait less stressful for your child. Please bring any information you have received regarding your child’s health, education or progress, a list of all medications, and a list of questions or concerns you may have for the specialist. If you only have one copy of these documents, just notify us once you reach your exam room and we can make copies and return them to you. We look forward to seeing you! Clinic Address: Medical Autism Clinic 1600 7th Avenue South McWane Building, Clinic 7 Birmingham, AL 35233

Page 1 of 6

MEDICAL AUTISM CLINIC EDUCATIONAL QUESTIONNAIRE (Over 5)

Child and Parent Information: Child’s Name: ___________________________________________________ Birth Date: _________________ Last First Middle Gender: Male Female Child’s Classroom/Age Level:___________________________________ Parent’s Name: ____________________________________Relationship to child:_______________________ Please have child care or school personnel fill out and return. Form Completed by ______________________________________ Date Completed:______________ Position/Title_____________________________________________ How long have you known the child?__________________ Child Care/School:_______________________________________________________________________ Address: ________________________________________________________________________________ Street City State Zip County Primary Phone:_____________________________Fax Number: _____________________________ What specific questions would you like answered that would help you better meet this child’s developmental and educational needs? 1) ________________________________________________________________________ 2) ________________________________________________________________________ 3) ________________________________________________________________________ Please describe the child’s strengths: Please describe any areas of functioning that need the most improvement: Any other specific concerns you have about this child? Besides English, are there any other languages used in the child’s instruction?

Page 2 of 6

Has the child ever been evaluated for learning or academic problems? ☐Yes ☐No If yes, when?______ Please send copies of previous testing results and copy of the current Individual Educational Plan.

ACADEMIC PERFORMANCE: Please circle the appropriate number below.

Excellent

Above Average

Average

Somewhat of a

problem

Problematic

1. Reading decoding 1 2 3 4 5 2. Reading comprehension 1 2 3 4 5 3. Reading rate and fluency 1 2 3 4 5 4.Spelling accuracy 1 2 3 4 5 5.Mathematics concepts 1 2 3 4 5 6.Mathematics computation 1 2 3 4 5 7.Handwriting 1 2 3 4 5 8. Writing rate 1 2 3 4 5 9. Punctuation/grammar 1 2 3 4 5 10.Ability to express thoughts through writing 1 2 3 4 5 11.Gross motor skills 1 2 3 4 5 12.Fine motor skills (using pencil & scissors) 1 2 3 4 5 13.Overall school performance 1 2 3 4 5

CURRENT CLASSROOM BEHAVIOR: Please circle the appropriate number below.

Excellent

Above average

Average

Somewhat of a

problem

Problematic

1. Understanding verbal instructions 1 2 3 4 5 2. Completing classroom assignments 1 2 3 4 5 3. Organizational skills 1 2 3 4 5 4. Getting homework to and from school

1 2 3 4 5

5. Completing homework 1 2 3 4 5 6. Relationship with peers 1 2 3 4 5 7. Following directions 1 2 3 4 5 8. Disrupting class 1 2 3 4 5 9. Verbally participating in class 1 2 3 4 5 10. Written expression 1 2 3 4 5 11. Handwriting 1 2 3 4 5

Page 3 of 6

LEARNING PROBLEMS: Circle the number that best describes the child’s learning problems (I.e., above and beyond what would be expected for his or her developmental age) over the past 6 months. Never or

rarely Occasionally Often Very

often 1. Has trouble learning new material in an appropriate time frame for age and skills

0 1 2 3

2. Has little desire to master new skills 0 1 2 3 3. Unable to tell time, days of the week, months of the year 0 1 2 3 4. Can’t repeat information 0 1 2 3

5. Knows material one day; doesn’t know it the next 0 1 2 3 6. Has trouble holding several different things in mind while working

0 1 2 3

7. Has trouble following multi-step directions 0 1 2 3 8. Has difficulty copying written material from blackboard 0 1 2 3

Office Use Only (Gen): (1-8)___/8 >4/8

9. Difficulty orienting self (i.e., gets lost, can’t find way, or gets turned around easily

0 1 2 3

10. Has poor spatial judgment and often bumps into things 0 1 2 3 11. Confuses directionality (up/down, left/right, over under) 0 1 2 3 12. Has poor spatial organization on paper (difficulty staying in lines, maintain space between words, staying within page margins)

0 1 2 3

13 .Mixes up capital and lower case letters when writing 0 1 2 3 14. Reverses letters and numbers 0 1 2 3

Office Use Only (VSP): (9-14)__/6 >3/6

15.Has trouble expressing words or events in correct order 0 1 2 3 16. Often mispronounces known or familiar words or uses wrong word

0 1 2 3

17. Has trouble verbally expressing thoughts 0 1 2 3 18. Says things that have little or no connection to what others are discussing

0 1 2 3

19. Has difficulty distinguishing long vowel sounds and short vowel sounds

0 1 2 3

20. Depends on teacher or others for repetition of task instructions 0 1 2 3 Office Use Only (Lang): (15-20)__/6 € > 3/6

21. Displays poor word attack skills (can’t sound out words) 0 1 2 3 22. Puts wrong number of letters in words 0 1 2 3 23. Confuses consonant sounds, e.g.: d-b, d-t, m-n, p-b, f-v, s-z 0 1 2 3 24. Unable to keep place on page when reading 0 1 2 3

Office Use Only (R/W): (21-24)___/4 € >2/4

CLASSROOM SETTING: Please check all that apply, and provide details. Type of setting Number of students Number of instructors Aide present for child? € Mainstream € 1:1 € Shared € None € Integrated € 1:1 € Shared € None € Substantially separate

€ 1:1 € Shared € None

Page 4 of 6

GENERAL EDUCATION SETTING: Please list any specific curricula or instructional methodologies used in the child’s general education setting, if applicable Academic area Methodology or curriculum Reading/reading-related materials

Mathematics

Writing/written expression

Please list services child receives through IEP: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Page 5 of 6

CHILD’S BEHAVIORAL AND EMOTIONAL FUNCTIONING Circle the number that best describes the child’s behavior OVER THE PAST 6 MONTHS

Never or Rarely

Occasionally Often Very Often

1. Fails to give close attention to detail or makes careless mistakes (e.g. homework)

0 1 2 3

2. Has difficulty attending to what needs to be done 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through when given directions 0 1 2 3 5. Has difficulties organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or does not want to start tasks 0 1 2 3 7. Loses things necessary for tasks or activities (school assignments, books, pencils, etc.)

0 1 2 3

8. Is easily distracted by noises or other things 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3

Office Use Only (I) (1-9)___/9 > 6/9 SUBTOTAL: _______

10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat when he/she is supposed to stay in seat 0 1 2 3 12. Runs about or climbs too much when he/she is supposed to stay seated

0 1 2 3

13. Has difficulty playing or starting quiet games 0 1 2 3 14. Is “on the go” or acts as if “driven by a motor” 0 1 2 3 15. Talks excessively 0 1 2 3 16. Blurts out answers before questions have been completed 0 1 2 3 17. Has difficulty waiting his/her turn 0 1 2 3 18. Interrupts or bothers others when they are talking or playing games

0 1 2 3

Office Use Only (H): (10-18) ___/9 > 6/9 SUBTOTAL:______

19. Loses temper 0 1 2 3 20. Actively disobeys or refuses to follow adult’s request or rules 0 1 2 3 21. Is angry or resentful 0 1 2 3 22. Is spiteful and vindictive 0 1 2 3 23. Bullies, threatens, or scares others 0 1 2 3 24. Initiates physical fights 0 1 2 3 25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)

0 1 2 3

26. Is physically cruel to people 0 1 2 3 27. Has stolen items of nontrivial value 0 1 2 3 28. Deliberately destroys others’ property 0 1 2 3

Office Use Only (ODD/CD) (19-28)/10 > 3/10

29. Is fearful, anxious, or worried 0 1 2 3 30. Appears self-conscious or easily embarrassed 0 1 2 3 31. Appears afraid to try new things for fear of making mistakes 0 1 2 3 32. Feels worthless or inferior 0 1 2 3 33. Blames self for problems, feels guilty 0 1 2 3 34. Feels lonely, unwanted, or unloved; complains that “no one loves me”

0 1 2 3

35. Appears sad, unhappy, or depressed 0 1 2 3 Office Use Only (Anx/Dep) (29-35) __/7 € > 3/7

Page 6 of 6

Never or Rarely

Occasionally Often Very Often

36. Skips school without permission 0 1 2 3 37. Has set fires on purpose to cause damage 0 1 2 3 38. Destroys other’s property on purpose 0 1 2 3 39. Has broken into someone else’s home, business or car 0 1 2 3 40. Has said things like “I wish I were dead” or has tried to hurt self 0 1 2 3 41. Has distinct periods where mood is unusually irritable or unusually good, cheerful, or high which is clearly excessive or different from normal mood

0 1 2 3

42. Seems to have compulsions (repetitive behaviors that this child seems driven to carry out, such as repeated hand washing, counting, or erasing until holes appear)

0 1 2 3

43. Has prolonged temper tantrums (greater than 20-30 minutes) 0 1 2 3 44. Seems unaware of other’ existence, is uninterested in interacting with others

0 1 2 3

45. Has odd, eccentric, or unusual preoccupations (e.g., clothing items, toys, neatness)

0 1 2 3

46. Appears uninterested in activities children his or her age usually like or participate in

0 1 2 3

Office Use Only (MH): (35-46) ___/11 € >/11 Please describe this child’s personality—moods, behavior, emotional functioning, etc. Please describe this child’s relationship with peers. Is there any other information you think would be helpful for evaluating this child? ___________________ _____________________ _________________________ Teacher Sign Print Date Completed ____________________ Relationship to Patient

Please send completed packet via mail or fax to: Medical Autism Clinic

1600 7th Avenue South, McWane Bldg, Dearth Tower Ste. 5602 Birmingham, AL 35233

Office: (205) 638-5277 Fax: (205)212-2997