Autism Care Questionnaire

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We want to make sure visits to the hospital or doctor are a positive experience. Please fill out this form to help us learn about you/the patient so we can better meet your/the patient's needs. If you have any questions, please contact the Lurie Center at LurieCenter@partners.org

M-D-Y

Yes No

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If the guardian is appointed by the court, a copy of the guardianship should be submitted to the hospital or doctor.

Talking

Sign Language

Typed words

Handwritten words

Tablet or communication device

Pointing/gesturing

Pictures or symbols

Pictures with words

Making sounds

Facial expressions (smiling, frowning, etc.)

Other

Talking

Sign Language

Typed words

Handwritten words

Tablet or communication device

Pointing/gesturing

Pictures or symbols

Pictures with words

Making sounds

Facial expressions (smiling, frowning, etc.)

Other

Talking

Sign Language

Typed words

Handwritten words

Tablet or communication device

Stories

Pictures or symbols

Pictures with words

To Do/Finished Boards

First/Then Boards

Other

Using a clock or watch

Using a timer

Using schedule boards

Counting aloud

Other

Talking

Sign language

Typed words

Handwritten words

Tablet or communication device

Pointing/gesturing

Pictures or symbols

Pictures with words

Making sounds

Crying

Facial expressions (frowning, etc.)

Hitting or hurting self

Hitting or hurting others

Other

Yes No

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Communicate with the patient (using the favored communication method) before each step of the exam

List or count things that the doctor needs to do; i.e. 1-look at eyes, 2-look in ears, 3-listen to heart, etc

Do parts of the exam on someone else first

Allow the patient to touch any instruments (i.e. stethoscope, blood pressure cuff) him or herself)

Hide instruments until their use becomes necessary

Distraction the patient from the examination

Other

Using a stethoscope to listen to lungs

Checking blood pressure with the cuff

Eye test

Ear test

Looking in mouth/throat

Belly Exam

Testing reflexes

Other

Yes No

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Yes No

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If no, please let us know before the patient comes to the hospital to discuss options since all patients must where a hospital ID.

Loud noises

Unexpected noises

Bright lights

Specific colors

Fragrances/smells

Textures

Touch

Specific types of touch

Other

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Talking

Sign language

Typed words

Handwritten words

Tablet or communication device

Pointing/gesturing

Pictures or symbols

Pictures with words

Making sounds

Facial expressions (smiling, frowning, etc.)

Physical motions (rocking, flapping, squeezing hands)

Hitting or hurting self

Hitting or hurting others

Other

Talk to him/her

Leave him/her alone

Give him/her some space

Other

A map of the hospital

Low Lighting

Sunglasses

Headphones to decrease noise

A heavy blanket

An escort that will help the patient around the hospital

Music

Videos

Puzzles/games

Other

Yes No

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/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^\d{4}-\d{4}$/

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