Autism Spectrum Disorder (ASD) Adults

ASD – Adult

Please complete this form if you think that you may have the condition Autism Spectrum Disorder (ASD) or Aspergers Syndrome which falls under ASD.

Completing. It takes around 30 minutes to complete. We advise you set aside this time in advance of starting the form. If you have poor internet connection then please write your typed answers in a word document first to prevent loss of answers if you lose connection. This form is particularly long so is best filled out on a PC rather than a phone. 

On Completion. We will assess your likelihood of ASD and book you for a GP consultation to discuss it. There are two outcomes:

  1. We do not think you have ASD.
  2. You are likely to have ASD. We will refer you to the Adult Mental Health Team. Unfortunately there is currently a waiting list for this specialty of around 2 years.

The Form. Made up of FIVE sections:

  1. Your details
  2. Supporting Evidence
  3. Your Symptoms
  4. The AQ-10 Test (an Autism test)
  5. The WEISS Test (a ‘how badly it affects you’ test)
A diagnosis of ASD will not be considered if you drink more than 30 units of alcohol per week or take regular recreational drugs (including cannibis)

YOUR DETAILS

Marital Status
Children?

SUPPORTING EVIDENCE

It is helpful to the Mental Health Service if you are able to provide evidence from family, friends, school or work suggesting symptoms of ASD.

It can be an old school report, a letter from a family member or friend or a work letter or disciplinary describing your difficulties. You can upload the document directly or just take a photo of them.

Maximum upload size: 52.43MB

YOUR SYMPTOMS

People with ASD have significant and pervasive difficulties in social interaction and understanding, social communication, inflexibility of thinking and repetitive behaviours/interests.

AUTISM SPECTRUM QUOTIENT (AQ-10)

© 2012 University of Cambridge

Please answer the questions below, rating yourself as best describes how you have felt and conducted yourself over your life.

1. I often notice small sounds when others do not
2. I usually concentrate more on the whole picture, rather than the small details
3. I find it easy to do more than one thing at once
4. If there is an interruption, I can switch back to what I was doing very quickly
5. I find it easy to ‘read between the lines’ when someone is talking to me
6. I know how to tell if someone listening to me is getting bored
7. When I’m reading a story I find it difficult to work out the characters’ intentions
8. I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc)
9. I find it easy to work out what someone is thinking or feeling just by looking at their face
10. I find it difficult to work out people’s intentions

WEISS Functional Impairment Rating Scale – Self Report (WFIRS-S)

© 2011 Margaret Danielle Weiss

Click the rating that best describes how your emotional or behavioural problems have affected each item in the last month with the exception of your experiences at school.

A. Family

1. Having problems with family
2. Having problems with spouse/partner
3. Relying on others to do things for you
4. Causing fighting in the family
5. Makes it hard for the family to have fun together
6. Problems taking care of the family
7. Problems balancing your needs against those of your family
8. Problems losing control with family

B. Work

1. Problems performing required duties
2. Problems with getting your work done efficiently
3. Problems with your supervisor
4. Problems keeping a job
5. Getting fired from work
6. Problems working in a team
7. Problems with your attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Poor performance evaluations

C. School

1. Problems taking notes
2. Problems completing assignments
3. Problems getting your work done efficiently
4. Problems with teachers
5. Problems with school administrators
6. Problems meeting minimum requirements to stay in school
7. Problems with attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Problems with inconsistent grades

D. Life Skills

1. Excessive or inappropriate use of internet, video games or TV
2. Problems keeping an acceptable appearance
3. Problems getting ready to leave the house
4. Problems getting to bed
5. Problems with nutrition
6. Problems with sex
7. Problems with sleeping
8. Getting hurt or injured
9. Avoiding exercise
10. Problems keeping regular appointments with doctor/dentist
11. Problems keeping up with household chores
12. Problems managing money

E. Self Concept

1. Feeling bad about yourself
2. Feeling frustrated with yourself
3. Feeling discouraged
4. Not feeling happy with your life
5. Feeling incompetent

F. Social

1. Getting into arguments
2. Trouble cooperating
3. Trouble getting along with people
4. Problems having fun with other people
5. Problems participating in hobbies
6. Problems making friends
7. Problems keeping friends
8. Saying inappropriate things
9. Complaints from neighbours

G. Risk

1. Aggressive driving
2. Doing other things while driving
3. Road rage
4. Breaking or damaging things
5. Doing things that are illegal
6. Being involved with the police
7. Smoking cigarettes
8. Smoking Marijuana
9. Drinking alcohol
10. Taking “street drugs”
11. Sex without protection (birth control, condom)
12. Sexually inappropriate behaviour
13. Being physically aggressive
14. Being verbally aggressive

WEISS Scores

You have made it to the end of the form. Well done! On submission we will be in touch with an appointment to discuss with a GP.
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.
Consent
© 2022 Kristian Turnbull