Transcription of Autism pathway pre- assessment questionnaire
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Autism pathway pre- assessment questionnaire
ADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNRelationship statusPlease tick:SingleMarriedDivorcedSeparatedWidow edLiving with partnerIn relationship but not living togetherPrefer not to answerAutism pathway pre- assessment questionnairePlease 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 for completing the questionnairePlease tick any YES/NO questions and answer all questions, providing additional details where necessary.
grandparents who may have a mental health condition): 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. Name and address of your GP Do you: Medical history Allergies: Allergic to:
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