ࡱ> 02-./q  _bjbjt+t+ -bAA6]8K*VLFx(z(z(z(z(z(z($+,2(lll(""""lx(lx(""x(x(4lPR)@F"Fx(New Jersey Department of Health NEW JERSEY AUTISM REGISTRY PO Box 364, Trenton, NJ 08625-0364 Fax: 609-292-8235AUTISM REGISTRATIONChild s informationName of Child (as appears on birth certificate)Last Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMCHECKBOX  None Given  FORMTEXT      Middle Name  FORMTEXT      Also Known AsLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMCHECKBOX  None Given  FORMTEXT      Middle Name  FORMTEXT      Child s Current Residence AddressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Hospital / Place of BirthMedical Facility Name or Description of Location  FORMTEXT        FORMCHECKBOX  UnknownCity  FORMTEXT      State  FORMTEXT      Country  FORMTEXT      Primary Care Provider Practice Name -OR- Provider Name (Last Name, First Name)  FORMTEXT       FORMCHECKBOX  Undecided  FORMCHECKBOX  UnknownTelephone Number Extension ( FORMTEXT      )  FORMTEXT        FORMTEXT      Birth InformationDate of Birth  FORMTEXT      Sex  FORMCHECKBOX  Female  FORMCHECKBOX  Male  FORMCHECKBOX  IndeterminateBirthweight  FORMTEXT _____ Grams -OR-  FORMTEXT       Lbs.,  FORMTEXT       Ozs. -OR-  FORMCHECKBOX  UnknownPlurality  FORMCHECKBOX  Single  FORMCHECKBOX  Twin  FORMCHECKBOX  Other Multiple:  FORMTEXT ___  FORMCHECKBOX  UnknownIf Multiple, Birth Order:  FORMTEXT      Weeks of Pregnancy  FORMCHECKBOX  Preterm (<37 Wks.)  FORMCHECKBOX  Term (37-41 Wks.)  FORMCHECKBOX  Post term (>42 Wks.)  FORMCHECKBOX  UnknownEthnicity InformationHispanic/Latino  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownPrimary Language Spoken in Home FORMCHECKBOX  English  FORMCHECKBOX  Spanish  FORMCHECKBOX  Other, Specify: FORMTEXT      Race (Check ALL that apply) FORMCHECKBOX  White  FORMCHECKBOX  Black/African American  FORMCHECKBOX  Chinese  FORMCHECKBOX  American Indian/Native Alaskan  FORMCHECKBOX  Japanese  FORMCHECKBOX  Native Hawaiian  FORMCHECKBOX  Korean  FORMCHECKBOX  Filipino  FORMCHECKBOX  Vietnamese  FORMCHECKBOX  Guamanian or Chamorro  FORMCHECKBOX  Asian Indian  FORMCHECKBOX  Samoan FORMCHECKBOX  Other Asian, Specify: FORMTEXT       FORMCHECKBOX  Other Pacific Islander, Specify: FORMTEXT       FORMCHECKBOX  Other, Specify: FORMTEXT       FORMCHECKBOX  Not Classifiable / UnknownBirth Mother s Residence at Time of Birth (If mother was institutionalized at time of birth, enter residence address before she was institutionalized.) FORMCHECKBOX  Unknown  FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Case Tracking informationInsurance informationMedical Record Number  FORMTEXT      Birth Certificate/VIP Number  FORMTEXT      Insurance Type  FORMCHECKBOX  None  FORMCHECKBOX  Private  FORMCHECKBOX  Medicaid  FORMCHECKBOX  UnknownINFORMATION ON PERSON SUBMITTING REPORTSubmitted by  FORMCHECKBOX  Diagnostician(s) or their Staff/Facility  FORMCHECKBOX  Case Manager (SCHS/EI)  FORMCHECKBOX  Primary Care Provider  FORMCHECKBOX  Other Health Care Provider/FacilityTitle  FORMCHECKBOX Dr.  FORMCHECKBOX Mr.  FORMCHECKBOX Ms.Name (Last, First)  FORMTEXT      Practice/Facility Name  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhoneStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Country (if not USA)  FORMTEXT      PARENT A informationParent A Vital Status  FORMCHECKBOX  Alive  FORMCHECKBOX  Dead  FORMCHECKBOX  UnknownSex  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleBiological  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownParent A NameLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      Maiden Name  FORMTEXT      Parent A Mailing Address FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Parent A Legal Guardian Status  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownDate of Birth  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhonePARENT B informationParent B Vital Status  FORMCHECKBOX  Alive  FORMCHECKBOX  Dead  FORMCHECKBOX  UnknownSex  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleBiological  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownParent B NameLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      Parent B Mailing Address FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Parent B Legal Guardian Status  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownDate of Birth  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhoneGUARDIAN INFORMATION IS TO BE COMPLETED ONLY IF NEITHER PARENT IS THE LEGAL GUARDIAN! guardian informationLegal Guardian Status  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownGuardian Type  FORMCHECKBOX  Relative  FORMCHECKBOX  Individual (Non-Relative)  FORMCHECKBOX  Government Agency (DCP&P, etc.)  FORMCHECKBOX  Private AgencyGuardian NameLast Name Suffix  FORMTEXT        FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      Contact InformationTelephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhoneMailing Address FORMCHECKBOX  Same as child s current residence addressStreet Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      IF AGENCY IS THE LEGAL Guardian, THEN COMPLETE GUARDIAN AGENCY INFORMATIONGuardian Agency InformationAgency Name  FORMTEXT      Division/Program  FORMTEXT      Street Address  FORMTEXT      Unit Description  FORMDROPDOWN Unit  FORMTEXT      P.O. Box  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County  FORMDROPDOWN Country  FORMTEXT      Guardian Agency Contact InformationContact Name (Last Name, First Name)  FORMTEXT      Telephone Number ( FORMTEXT      )  FORMTEXT        FORMCHECKBOX  No PhoneREGISTRATIONRegistering this Child for:  FORMCHECKBOX  First Registration  FORMCHECKBOX  Updated Registration  FORMCHECKBOX  Audit FORMCHECKBOX  YES, Parent/Guardian Requests NonIdentifiable Autism RegistrationDIAGNOSTICIAN INFORMATIONName (Last, First)  FORMTEXT      Highest Degree  FORMCHECKBOX  MD/DO  FORMCHECKBOX  Doctorate  FORMCHECKBOX  Masters  FORMCHECKBOX  UnknownSpecialty  FORMCHECKBOX  Family Practice  FORMCHECKBOX  PediatricsGeneral  FORMCHECKBOX  PediatricsNeurology  FORMCHECKBOX  Social Work  FORMCHECKBOX  Neurology  FORMCHECKBOX  Pediatrics-Developmental/  FORMCHECKBOX  PediatricsPsychiatry  FORMCHECKBOX  Other (specify):  FORMTEXT ________________  FORMCHECKBOX  Neuropsychology Neurodevelopmental  FORMCHECKBOX  Psychology  FORMCHECKBOX  UnknownName of Practice/Facility where Diagnosis Made  FORMTEXT      AUTISM DIAGNOSIS INFORMATION FORMCHECKBOX  Autism Spectrum Disorders (ASD) IF PREVIOUSLY DIAGNOSED, SPECIFY TYPE (ChooseOne):  FORMCHECKBOX  Autistic Disorder  FORMCHECKBOX  Pervasive Developmental Disorder NOS  FORMCHECKBOX  Asperger s Disorder  FORMCHECKBOX  No Longer Meets Criteria  FORMCHECKBOX  NEVER Met CriteriaDate of Diagnosis (Month/Day/Year)  FORMTEXT      Is this the FIRST TIME this child has been diagnosed with an ASD?  FORMCHECKBOX  Yes  FORMCHECKBOX No If NO, then at what age was this child diagnosed with an ASD?  FORMTEXT       Years  FORMTEXT       MonthsAge Symptoms First Noted by Anyone?  FORMTEXT       Years  FORMTEXT       Months  FORMCHECKBOX  UnknownInstruments/References Used (check all that apply):  FORMCHECKBOX  ABC Autism Behavior Checklist  FORMCHECKBOX  ADI-R Autism Diagnostic Interview - Revised  FORMCHECKBOX  ADOS Autism Diagnostic Observation Schedules  FORMCHECKBOX  CARS Childhood Autism Rating Scale  FORMCHECKBOX  DSM-5 Diagnostic and Statistical Manual, 5th Ed.  FORMCHECKBOX  DSM-IV-TR Diagnostic and Statistical Manual, 4thEd.-TR  FORMCHECKBOX  GARS-3 Giliam Autism Rating Scale  FORMCHECKBOX  Other (specify):  FORMTEXT __________________________If Diagnosed using the DSM-5, indicate the levels of support needed for: Restricted, Repetitive Behavior Severity Levels:  FORMCHECKBOX  Level 3: Requiring VERY substantial support  FORMCHECKBOX  Level 2: Requiring substantial support  FORMCHECKBOX  Level 1: Requiring support Social and Communication Severity Levels:  FORMCHECKBOX  Level 3: Requiring VERY substantial support  FORMCHECKBOX  Level 2: Requiring substantial support  FORMCHECKBOX  Level 1: Requiring support  FORMCHECKBOX  Unknown/Not AssessedAdditional Diagnoses (Check all that apply) NOTE: All Congenital Diagnoses should be listed below.  FORMCHECKBOX  ADHD/ADD  FORMCHECKBOX  Schizophrenia  FORMCHECKBOX  Tic Disorder/Tourettes  FORMCHECKBOX  Obesity  FORMCHECKBOX  Depression  FORMCHECKBOX  Anxiety, including OCD  FORMCHECKBOX  Seizure Disorder/Epilepsy  FORMCHECKBOX  Eczema  FORMCHECKBOX  Mood/Bipolar  FORMCHECKBOX  Oppositional Defiant Disorder  FORMCHECKBOX  Asthma  FORMCHECKBOX  Intellectual DisabilityOTHER DIAGNOSIS INFORMATIONOther Diagnosis Descriptions (Be Specific and include all congenital diagnoses):1. FORMTEXT      4.2. FORMTEXT      5.3. FORMTEXT      6.SYMPTOMS/BEHAVIORS INFORMATIONVerbal Ability at the Time of Registration  FORMCHECKBOX  Nonverbal (no language at all)  FORMCHECKBOX  Limited verbal skills (specify all that apply below, if known):  FORMCHECKBOX  Stereotyped and repetitive use of language (echolalia)  FORMCHECKBOX  Problems taking steps to start a conversation/lacking pragmatic language  FORMCHECKBOX  Uses mostly sign language/assistive devices to get needs met  FORMCHECKBOX  Difficulty understanding others when spoken to  FORMCHECKBOX  Verbal skills appropriate for developmental age  FORMCHECKBOX  UnknownSymptoms/Behaviors at the Time of Registration (Checkallthat apply):  FORMCHECKBOX  Aggressiveness towards others  FORMCHECKBOX  Constipation/gastro-intestinal issues  FORMCHECKBOX  Coordination issues/motor skills difficulties  FORMCHECKBOX  Excessive tantrums not due to developmental age  FORMCHECKBOX  Feeding disorder/difficulties  FORMCHECKBOX  Hyperlexia  FORMCHECKBOX  Self-injurious behavior  FORMCHECKBOX  Sensory integration issues  FORMCHECKBOX  Sleep disruptions/disturbances  FORMCHECKBOX  Wandering/elopement  FORMCHECKBOX  UnknownIntellectual Disability/Cognitive Impairment  FORMCHECKBOX  Not measured/assessed or unknown  FORMCHECKBOX  IQ is 71 to 85  FORMCHECKBOX  IQ score is 70 or below  FORMCHECKBOX  IQ is above 85MEDICATION INFORMATIONMedication(s) Used at the Time of Registration (Check all that apply):  FORMCHECKBOX  Alpha Agonist (guanfacine, clonidine)  FORMCHECKBOX  Anticonvulsants (barbiturates, aldehyde, Depakote, Lamictal)  FORMCHECKBOX  Antidepressants-SSRI (Prozac, Zoloft, Lexapro)  FORMCHECKBOX  Antidepressants-Trycyclic, SSNRI, etc. (Cymbalta, Wellbutrin, Elavil)  FORMCHECKBOX  Anxiolytics (Buspar, Ativan)  FORMCHECKBOX  CAMS (Complementary/Alternative) (massage therapy, yoga, acupuncture)  FORMCHECKBOX  Neuroleptics (Risperdal, Abilify, Seroquel)  FORMCHECKBOX  Non-stimulants (Strattera)  FORMCHECKBOX  Nutritional Supplements (vitamins, minerals, herbs)  FORMCHECKBOX  Sleep Aid (Ambien, Lunesta, Rozerem, or melatonin)  FORMCHECKBOX  Stimulants (Ritalin, Adderall)  FORMCHECKBOX  Other (specify):  FORMTEXT ________________  FORMCHECKBOX  UnknownDoes the child have a sibling(s) diagnosed with an ASD?  FORMCHECKBOX  Yes How many?  FORMTEXT ______  FORMCHECKBOX  No  FORMCHECKBOX  Unknown AUTISM REGISTRATION (Continued) SCH-1 NOV 16 Page  PAGE 2 of  NUMPAGES 3 Pages. 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