Autism

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Autism Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of diagnosis:
Does the client live independently?
- Yes
- No
Currently working?
- Yes
- No
Select the option that best describes the autism:
- Asperger’s syndrome/High functioning (IQ above 70, None or very minimal impairment in sensorimotor ability, well developed language skills)
- Mild (IQ 50-70, minimal impairment in sensorimotor ability, ability to acquire grade school academic skills, vocational skills for selfsupport may be achieved, may need assistance or guidance if stressed but may also be able to live independently or with limited supervision)
- Moderate (IQ 35-49, able to acquire some communication skills with training, academic skills limited to early grade school level, social skills significantly impaired but may be able to perform unskilled or semi-skilled labor under supervision)
- Severe (Poor motor development, minimal speech and little or no communication skills, not able to live independently)
- Profound (IQ < 20, none to minimal speech and communication skills, need to live in a closely supervised environment)
History of seizures?
- Yes
- No
If yes, please specify the type of seizure:
- Grand mal
- Petit mal
- Partial seizure-complex
- Focal
Symptoms experienced with seizures (select all that apply):
- Unconsciousness
- Clouded consciousness
- Uncontrolled twitching
- Deep sleep
- Other
If other symptoms, provide details:
Frequency of seizures:
Date of last seizure:
Date Format: MM slash DD slash YYYY
Any associated mental health or behavioral disorder (e.g. obsessive compulsive disorder, anxiety, panic attacks, depression or other) If yes, provide details:
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

Autism

Autism Questionnaire