Western Region ASERT Collaborative Western Psychiatric Institute and Clinic of UPMC Center for Autism and Developmental Disabilities

The purpose of this instrument is to allow individuals with autism spectrum disorder, their families and their caregivers to inform healthcare providers on the nature of their condition and how best to support their medical or behavioral concerns. Please provide as much detail as possible in response to the questions to allow the clinical staff to optimize the care of you or your loved one in this setting.

Name: ______Date of Birth: ______

Emergency Contact(s) and Number: ______

Primary Care Provider and Number: _______

Baseline Characteristics

Communication Ability (e.g., verbal, fluent, non-verbal, sign, repetition) Use of Communication Devices/Apps: ______

Social Interaction (e.g., avoids eye contact and Interaction, limited reciprocity, Interacts with prompts / Assistance): ______

Behavioral Patterns / include restricted, repetitive and/or rituals (e.g., when anxious, agitated, calm, Nonresponsive):______

Dietary Patterns (e.g., Favored Foods, Timing and Normal Amounts of Oral Intake): ______

Vaccination History (e.g., All Scheduled Vaccines, Particular Refused Vaccines): ______

Menstrual History (e.g., Date of First Period, Pattern and Nature of Menses – irregular, heavy): ______

Other Co-occurring Conditions (e.g., Seizures, Respiration, Dental, Constipation, Depression, Anxiety, Dental: ______

Precautions: ___Yes ___No, Advanced Directive ___No ___ Yes If Yes, Specifics: Medical/Behavioral Health, Trauma/Abuse, Sexual Concerns, Self-Injurious / Mutilating Behavior, PICA (ingesting of inedibles), Aggression, Property Destruction, ______

Home Medications and Other Therapies (e.g., Agents and Dosage, Specialized Diets or Supplements): ______

Allergies: __Yes __No: If yes, list:______

Sleep Pattern (e.g., Average number of Hours and Pattern of Sleep): ______

Comfort (Transitional) Object(s): ______

Management in the Clinic / Emergency Department(ED)

Are there specific environmental factors that might agitate this individual (e.g., cold, lighting, textures)? ______

Are there specific communication techniques that might agitate this individual (e.g., direct eye contact, loud or simultaneous voices, specific words or phrases)? ______

How does this individual communicate or respond to directives? yes and no (e.g., typical words, gestures, phrases)? ______

What is the best way to communicate with this individual (e.g., verbally, gestures, pictures, communication device, written)? ______

How does this individual express pain (e.g., body positioning, verbally (perseveration), gestures, (pointing) crying, facial grimace, self-injurious behavior, excessive rituals)? ______

How does this individual express frustration/anger or indicate agitation (e.g., repeating words or phrases motor rituals (pacing, body rocking, hand posturing / flapping / meltdown)? ______

List behavioral approaches that are effective in preventing challenging behaviors as well as de-escalation and reinforcing safe and compliant responding: ______

Does this individual use or respond to a technique to remain calm (e.g., swaying, breathing, I-pad, command “ready hands”, sensory items)? ______

Does this individual respond to a particular distraction technique at time of stress or in previous medical situations (e.g., music, photos, books, use of a communication device)? ______

Can this individual swallow pills? ___ YES ___NO

Is there a flavor in oral intake that this individual likes or dislikes? ______

What medications, if any, has this individual received that has worked well for calming, sedation or pain management? ______

What medications, if any, has this individual received that should be avoided when providing sedation or pain management? ______

Any other advice to the health care provider for treating this individual (e.g., keep voice in a low volume, avoid multiple health care providers, use yes and no questions, avoid removing a comforting object, hands off approach)? ______

Adapted from Venkat, A., Migyanka, J., M., Cramer, R., & McGonigle, J.J. (2016). An Instrument to Prepare for Acute Care of the Individual with Autism Spectrum Disorder in the Emergency Department. Journal of Autism and Developmental Disorders, Autism Dev Disord,46:2565-2569