1455 Autism Pre Assessment Questionnaire

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
Relationship status Please tick:

Single
Married
Divorced
Separated
Widowed
Living with partner
In relationship but not living together
Prefer not to answer
ADHD and autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5PN
Current accommodation status
Accommodation status Please tick:

Living alone
Living with partner
Living with parents
Sheltered/temporary accommodation
No fixed address
Other (please specify):
Do you have a carer? Yes No

If yes, name and address of your carer
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
Name Gender Date of birth Relationship to Details of any mental

you (eg. wife, health/physical health/
daughter, adopt- other diagnoses
ed son etc.)
Are you currently receiving any of the following benefits?
Disability Living Allowance/PIP Yes No

Employment Support Allowance Yes No
Housing Benefit Yes No
Other (please give details) Yes No
Have you ever been investigated by the Police or charged with a criminal offence?
(e.g. cautions/convictions/court appearances/imprisonment)
Yes No
If yes, please give further details including charges and dates:
Education
What type of school did you attend?
School type Please tick:
Mainstream state school
Mainstream private school
School for children with behavioural and/or emotional difficulties
Specialist school for children with autism
School for children with severe learning disabilities
School for children with moderate learning disabilities
School for children with physical disabilities and/or sensory impairments
Language unit within a school
Other (please specify):
Have you ever received a Statement of Special Educational Needs (SEN) or had an Educational
Health Care Plan (EHCP) during your education?
Yes No
Please state your highest level of qualification to date:
Qualification Please tick:
O level/CSE/GCSE
AS Level
A Level
BTEC or equivalent
NVQ
Higher National Diploma
First degree or equivalent professional qualification
Higher degree (e.g. Masters, PhD)
Other (please give details):
Employment
Are you currently in paid employment? Yes No

Please give a brief list of your past employment to date and why you left:
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?
Yes No
If yes, please could you give us some details?
Has your mother ever been diagnosed with any physical health conditions?
Yes No
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?
Yes No
Has your father ever been diagnosed with any physical health conditions?
Yes No
Do you have any children who do not live with you? Yes No
If yes, please complete the following information for each of your children.
Name Gender Date of birth Living or Details of any mental health/
deceased physical health/other diagnoses
Do you have any brothers or sisters? Yes No

If yes, please complete the following information for each of your siblings.
Name Gender Date of birth Living or Details of any mental health/

deceased physical health/other diagnoses
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):
Medical history
Name and address of your GP
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.
Allergies: Yes No
Allergic to:
What happens when exposed
Current medication
Do you:
Smoke cigarettes/tobacco? Yes No
If yes, how many cigarettes do you smoke a day?
1-5 5-10 10-15 15-20 20+
Smoke cannabis?
If yes, how much cannabis do you smoke each day? (e.g. number of joints, ounces of cannabis)
Do you have any diagnosed physical health conditions? Yes No
If yes, please give details:
Have you ever been diagnosed with the following?
Autism spectrum disorder (including Asperger’s)

Yes No
Tourette’s syndrome
Yes No
Obsessive compulsive disorder (OCD) Yes No
(General) Anxiety disorder
Yes No
Depression
Yes No
Dyspraxia
Yes No
Dyslexia
Yes No
Dyscalculia
Yes No
Learning disability or global developmental delay
Yes No
Yes
Any genetic disorder No
Sleep disorder
Yes No
Visual problems
Yes No
Hearing problems
Yes No
Language delay or other language disorders Yes No
Schizophrenia
Yes No
Bipolar disorder
Yes No
Personality disorder
Yes No
Substance misuse Yes No
Any other mental health condition Yes No
If yes, please give details:
Have you ever felt suicidal? Yes No

If yes, have you ever planned or attempted suicide? Yes No
If yes, please give some details:
Have you ever been referred to any other of the following professionals?
Psychiatrist Yes No
Clinical psychologist
Yes No
Educational psychologist Yes No
Forensic psychologist
Yes No
Nurse Yes No
Speech and language therapist
Yes No
Occupational therapist
Yes No
Social worker
Yes No
Probation officer Yes No
Support worker Yes No
Disability employment advisor
Yes No
Other (give details)
Yes No
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.):
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)
Problem Not at Several More Nearly
all days than half every day
the days
1 Little interest or pleasure in doing things
2 Feeling down, depressed, or hopeless
3 Trouble falling or staying asleep, or sleeping too
much
4 Feeling tired or having little energy
5 Poor appetite or overeating
6 Feeling bad about yourself – or that you are a
failure or have let yourself or your family down
7 Trouble concentrating on things, such as reading
the newspaper or watching television
8 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 edge
11 Not being able to stop or control worrying
12 Worrying too much about different things
13 Trouble relaxing
14 Being so restless that it is hard to sit still
15 Becoming easily annoyed or irritable
16 Feeling afraid as if something awful might hap-
pen
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?
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…
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
2. If you ticked YES to more than one of the above, have several of these
ever happened during the same period of time?
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?
No problem Minor problem Moderate problem Severe problem
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?
Alcohol
(please tick the answer that is correct for you)
1. How often do you have a drink containing alcohol?
Never Monthly 2-4 times a month 2-3 times a week 4 or more times a
week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2 3 or 4 5 or 6 7 to 9 10 or more
3. How often do you have six or more drinks on one occasion?

Never Less than monthly Monthly Weekly Daily or almost daily
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?

No Yes, but not in the last year Yes, during the last year
10. Has a relative, friend, doctor or any other health worker been concerned about your
drinking or suggested you cut down?
No Yes, but not in the last year Yes, during the last year
Drugs
These questions refer to the past 12 months (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)?
Brain injury (please mark your answer with a tick)

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 quotient
Below 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 Strongly Slightly Slightly Strongly
agree agree disagree disagree
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 people
7 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.
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.
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.
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.
Statement Definitely Slightly Slightly Definitely

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.
Statement Definitely Slightly Slightly Definitely
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.).
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 Centre
University 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 Mathematicians
Journal of Autism and Developmental Disorders 31:5-17
©MRC-SBC/SJW Feb 1998
ADHD screening
Please 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.
Statement Never Rarely Some- Often Very

times 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?
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: Yes No
Thank you for taking the time to complete this questionnaire. Please check you have
answered all questions before returning it to us.
JOB NO 1455 FEB 20

1455 Autism Pre Assessment Questionnaire

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Autism pathway pre-

Instructions for completing the questionnaire

Daytime telephone number

Your personal information

Current relationship status

Relationship status Please tick:

Accommodation status Please tick:

Do you have a carer? Yes No

Name Gender Date of birth Relationship to Details of any mental

Disability Living Allowance/PIP Yes No

Are you currently in paid employment? Yes No

Please complete the following information about your mother:

If yes, please could you give us some details?

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

If yes, please could you give us some details?

Do you have any brothers or sisters? Yes No

Name Gender Date of birth Living or Details of any mental health/

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

Have you ever been diagnosed with the following?

Autism spectrum disorder (including Asperger’s)

Have you ever felt suicidal? Yes No

Name Profession/service Date seen Current or past involvement

Not difficult at all Somewhat difficult Very difficult Extremely difficult

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

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

Brain injury (please mark your answer with a tick)

The adult autism spectrum quotient

Statement Definitely Slightly Slightly Definitely

S. Baron-Cohen, S. Wheelwright, R. Skinner, J. Martin and E. Clubley, (2001)

Statement Never Rarely Some- Often Very

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

JOB NO 1455 FEB 20

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