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Adult autism (ASD) medical questionnaire

Adult Autism Spectrum Disorder medial questionnaire

Section

Type of appointment:

Medical history checklist

Please clarify if you have a history of any of the following conditions:

Congenital heart disease or previous cardiac surgery.
History of sudden death in a first-degree relative under 40 years of age.
Shortness of breath on exertion compared with peers.
Fainting on exertion or in response to fright or noise.
Palpitations that are rapid, regular and start and stop suddenly.
Fleeting occasional bumps are usually ectopic and do not need investigation.
Chest pain suggesting cardiac origin.
Signs of heart failure.
A murmur heard on cardiac examination.
Alcohol misuse.
Drug misuse.

Measurements

Please take the following measurements:

Please add both values, for example ‘120/80’.
This must be the resting pulse rate.
In centimetres.
In kilograms.

Important: Please note

For ADHD Direct patients looking to obtain their height, weight, and blood pressure measurements, there are a couple of convenient options available. Firstly, you can consider purchasing the necessary equipment online at affordable prices. A digital scale can provide accurate weight readings, and a blood pressure monitor can
help you monitor your blood pressure levels.

Alternatively, visiting your local pharmacy, general practitioner (GP) or practice nurse – are other viable option. These Clinicians typically have the required equipment and expertise to measure height, weight, and blood pressure accurately. They can provide professional guidance and ensure the accuracy of your measurements.

Significant medical conditions

Please clarify if you have any history (past or current) of the following conditions:

Hypertension:
Heart disease:
Epilepsy / seizures:
Hyperthyroidism (overactive thyroid):
Glaucoma:
Motor tics or Tourette’s syndrome:
Pregnancy or breastfeeding:
Bipolar disorder:
Psychosis:
Vasculitis:
Phaeochromocytoma:
Allergies:
Anorexia, bulimia, or any other eating disorder:
Alcohol usage:
Drug usage: