Parental Questionnaire (CONFIDENTIAL) ver.3
Answers marked with a * are required.
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  Autism Treatment Plus would like to thank you for taking time to fill out this questionnaire. Your responses will assist in understanding your child's condition and will help through research to treat other children.
 
E-mail
 
 
 
Today's date
(dd/mm/yyyy)
 
 
 
Child's Name
(first name, last name)
 
 
 
Father's Name
(first name, last name)
 
 
 
Mother's Name
(first  name, last name)
 
 
 
Please state whether both the parents live together?
      
 
 
 
Address
Address Line 1
Address Line 2
City/Town
Postal Code
 
 
 
Phone Number
Home
Mobile
 
 
 
Skype Username
 
 
 
GP's name
(first name, last name)
 
 
 
GP's Address
Address line 1
Address line 2
City/Town
Postal Code
Contact number
 
 
 
INFORMATION ON THE ASD CHILD
  
 
 
Date of birth
(dd/mm/yyyy)
 
 
 
Gender
 
 
 
Ethnicity
      
 
 
 
Weight (kg)
Height (cm)
 
 
 
How many siblings does your autistic child have?
 
 
 
What order was the autistic child born in?
(e.g. '1st' if they are the eldest sibling, '2nd' if they are the second eldest sibling, etc.)
 
 
 
Sibling details (1)
Name
Gender
Age
 
 
 
How would you describe the health condition of Sibling 1?
      
 
 
 
If you have answered 'average' or 'poor' please state why?
 
 
 
Sibling details (2)
Name
Gender
Age
 
 
 
How would you describe the health condition of Sibling 1
      
 
 
 
If you have answered 'average' or 'poor' please state why?
 
 
 
Details of any other siblings
 
 
 
 
 

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