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Required format:

Autism Care Questionnaire

Returning?

A A A

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

Date:

M-D-Y

Patient name:

* must provide value

Patient date of birth:

* must provide value

M-D-Y

Patient current age:

Name of person completing this form:

Relationship to the patient:

Email address of person completing this form:

Does the patient have a guardian?

Yes No

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Guardian name:

Guardian contact information:

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

1. How does the patient like to communicate needs/wants?

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

If other, please explain:

2. What other ways will the patient tell us what he/she needs/wants?

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

If other, please explain:

3. How does the patient communicate "yes" or "no" when asked a question?

4. How does the patient learn new information or instructions?

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

If other, please explain:

5. How does the patient know that time is passing?

Using a clock or watch

Using a timer

Using schedule boards

Counting aloud

Other

If other, please explain:

6. What is the best way for us to prepare the patient for tests? (i.e. how long the wait will be for a test or how long the test will take)?

7. How will the patient tell us that he/she has to go to the bathroom?

8. How will the patient tell us that he/she is hungry or thirsty?

9. How will the patient tell us if he/she is in pain?

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

If other, please explain:

10. Are there other ways the patient will let us know that he/she is in pain?

Yes No

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If yes, what ways?

1. How should we greet the patient?

2. What is the best way for us to examine the patient?

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

If other, please explain:

3. Is there a part of the exam that may especailly bother the patient?

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

If other, please explain:

4. Will the patient wear a hospital gown?

Yes No

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If no, what would the patient want to wear?

5. Will the patient wear a hospital ID band on their wrist?

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.

1. Is the patient sensitive to:

Loud noises

Unexpected noises

Bright lights

Specific colors

Fragrances/smells

Textures

Touch

Specific types of touch

Other

If other, please explain:

2. How long does the patient usually sleep at night?

3. Will a family member or caregiver be staying with the patient?

Yes No

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If yes, what hours will the caregiver be at the hospital?

4. Are there special ways to make mealtimes easier?

Yes No

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If yes, what ways?

5. Is the patient on a special diet?

Yes No

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If yes, what type?

6. Are there special times of the day that the patient eats snacks or meals?

Yes No

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If yes, what times?

7. Does the patient prefer that different foods in a meal not touch, or to have separate plates for each type of food?

Yes No

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If yes, what does the patient like?

8. Are there any words, phrases or actions that will upset the patient?

Yes No

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If yes, what are they?

9. How will the patient let us know if he/she is upset/anxious?

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

If other, please explain:

10. What comforts the patient when he/she gets upset or anxious?

Talk to him/her

Leave him/her alone

Give him/her some space

Other

If other, please explain:

11. What may help decrease the patient's anxiety?

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

Please Explain

12. Are there any other safety concerns we should know about?

Yes No

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If yes, what are the concerns?

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13. Is there anything else we should know about so we can make the patient's visit as positive as possible?

Expand

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