Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 13
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13FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)
SPONSOR NAME
SPONSOR SSN (Last four)
ADDENDUM 3 - AUTISM SPECTRUM DISORDERS AND SIGNIFICANT DEVELOPMENTAL DELAYS:
To be Completed by a Qualified Medical Professional
Complete addendum if the patient has been evaluated or received treatment(s) for autism spectrum disorders
and/or significant developmental delays.
2. DATE OF BIRTH
1.a. DIAGNOSIS(ES)
b. AGE WHEN DIAGNOSED
(YYYYMMDD)
Autism Spectrum Disorder
Global Developmental Delay
Other (Specify)
c. DIAGNOSED BY:
Child Psychologist
Child Psychiatrist
Developmental Pediatrician
Other Physician
Medical Multidisciplinary Team
School-Based Team
Other (Specify)
3. COEXISTING DIAGNOSES
(X all that apply)
Chromosomal Abnormalities
Intermittent Explosive Disorder
Major Depressive Disorder, Depressive Disorder, NOS
Obsessive Compulsive Disorder
Circadian-Rhythm Sleep Disorder
Seizure Disorder
Attention Deficit/Hyperactivity
Generalized Anxiety Disorder,
Other (Specify)
Disorder
Anxiety Disorder, NOS
4. CURRENT MEDICATIONS
(Used to treat diagnoses on this page)
a. CURRENT MEDICATION(S)
b. DOSAGE
c. FREQUENCY
d. REASON PRESCRIBED
5. CURRENT INTERVENTION THERAPIES
b. SCHOOL
c. TRICARE
d. OTHER SOURCE
e.
a. TYPE
(To be completed by a qualified medical professional
HOURS/WEEK
HOURS/WEEK
HOURS/WEEK
OTHER
in consultation with the family)
(If known)
(If known)
(If known)
(Identify)
(1) Speech Therapy
(2) Occupational Therapy
(3) Physical Therapy
(4) Psychological Counseling
(5) Intensive Behavioral Intervention (Includes ABA)
(6) OTHER (Specify)
7. OTHER INTERVENTIONS/THERAPIES USED BY THE FAMILY
6. COMMUNICATION
(Specify alternate or
(X )
complementary therapies)
VERBAL
NON-VERBAL (Uses:)
Signing
Communication Device
Picture Exchange Communication
8. BEHAVIOR: CHILD EXHIBITS HIGH RISK OR DANGEROUS BEHAVIOR
System (PECS)
Combination
YES
NO (If Yes, provide details in Item 13 below)
9. COGNITIVE ABILITY
10. EDUCATION
(X )
(X )
<50
50 - 70
>70
Receives Early Intervention
Receives Special Education
Attends Public School
Unknown
Indeterminate
Attends Private School
Attends Special Private School
Is Home Schooled
11. REQUIRED MEDICAL SERVICES
12. RESPITE CARE RECEIVED
a. HOURS PER
(X)
a. TYPE
b. FREQUENCY
(X)
a. TYPE
b. FREQUENCY
b. SOURCE
MONTH
Child Neurology
Child Psychology
Developmental
Child Psychiatry
Pediatrics
13. GENERAL COMMENTS
(Include Functional Levels)
14.a. PROVIDER PRINTED NAME OR STAMP
b. SIGNATURE
c. DATE (YYYYMMDD)
e. OFFICIAL E-MAIL ADDRESS
d. TELEPHONE NUMBERS (Include Area Code/Country Code)
f. MEDICAL SPECIALTY
(1) COMMERCIAL
(2) DSN (Military only)
DD FORM 2792 (ADDENDUM 3), AUG 2014
Page 11 of 11 Pages
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