III-3. Autism Spectrum (PAST 30 DAYS) development appears Evidence of mild symptoms Child has been diagnosed by Severe autism. Symptoms Child’s normal in relation to autistic of an autism spectrum an appropriate professional are disabling in at least one characteristics or this disorder. Child / youth may as having an autism area of life skills. information is unknown to meet criteria for Aspergers spectrum disorder. me. disorder. If the needs / functioning fall within a shaded box, explain why: child’s III-4. Communication (PAST 30 DAYS) ability to communicate Child is able to understand Child has limited abilities to Child is unable to Child’s is age appropriate or this others but may have limited understand others and communicate. information is unknown to ability to express him / her express him / her self. me. self. If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages 5 to 21) (Continued) III-5. Self Care and Daily Living Skills Eating, Bathing, Dressing, Toileting (PAST 30 DAYS) – self care / daily living Child requires excessive Child requires assistance Child requires complete Child’s skills appear to be age verbal prompting on self-care (physical prompting) on assistance on more than appropriate or this tasks or daily living skills. multiple self care tasks or one self care task (eating, information is unknown to complete assistance on one bathing, dressing, me. self care task. toileting). If the needs / functioning fall within a shaded box, explain why: child’s III-6. Medical Needs (PAST 30 DAYS) Child is healthy or this Child has some medical Child has chronic illness that Child has life threatening information is unknown to me problems that require medical requires ongoing medical illness or medical condition / does not apply. treatment (includes controlled intervention (diabetes, (active cancer, AIDS, asthma). severe / uncontrolled etc.). asthma, life threatening allergies, HIV). List medical condition (within the last 30 days):
III-3. Autism Spectrum (PAST 30 DAYS) Child’s development appears normal in relation to autistic characteristics or this information is unknown to me. Evidence of mild symptoms of an autism spectrum disorder. Child / youth may meet criteria for Aspergers disorder. Child has been diagnosed by an appropriate professional as having an autism spectrum disorder. Severe autism. Symptoms are disabling in at least one area of life skills. If the child’s needs / functioning fall within a shaded box, explain why: III-4. Communication (PAST 30 DAYS) Child’s ability to communicate is age appropriate or this information is unknown to me. Child is able to understand others but may have limited ability to express him / her self. Child has limited abilities to understand others and express him / her self. Child is unable to communicate. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages 5 to 21) (Continued) III-5. Self Care and Daily Living Skills – Eating, Bathing, Dressing, Toileting (PAST 30 DAYS) Child’s self care / daily living skills appear to be age appropriate or this information is unknown to me. Child requires excessive verbal prompting on self-care tasks or daily living skills. Child requires assistance (physical prompting) on multiple self care tasks or complete assistance on one self care task. Child requires complete assistance on more than one self care task (eating, bathing, dressing, toileting). If the child’s needs / functioning fall within a shaded box, explain why: III-6. Medical Needs (PAST 30 DAYS) Child is healthy or this information is unknown to me / does not apply. Child has some medical problems that require medical treatment (includes controlled asthma). Child has chronic illness that requires ongoing medical intervention (diabetes, severe / uncontrolled asthma, life threatening allergies, HIV). Child has life threatening illness or medical condition (active cancer, AIDS, etc.). List medical condition (within the last 30 days):