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[VLN-APAP] Saddle Rock Intake Questionnaire

Section 1: Excluding Factors Qualification for ALL Children

NOTE: This section has excluding factors. If a mom has multiple impacted children, this section determines if they all can qualify or if they all cannot qualify.

Excluding Factors Qualification for ALL Impacted Children If a client DNQs in this section, they DNQ for BOTH APAP and Topamax.

Your Full Name *

Email *

Phone *

Section 2: Per Child Excluding Factors Qualification - Up to 4 Children

NOTE: This section is for EACH Child listed in Q1 of Section 2.

Did you suffer from gestational diabetes, gestational hypertension, an infection and related fever that required hospitalization during pregnancy? If yes, DNQ for that child. *

Was your child/children born before the 26th week of pregnancy? If yes, DNQ for that child. *

Section 3: Topamax Qualification

NOTE: This section is specific to Topamax for EACH Child.

Section 4: Acetaminophen Qualification

NOTE: This section is specific to Acetaminophen for EACH Child.

Part 6: Topamax Additional Questions

Section 1: Mother’s Personal Information

Address (Topamax)

Section 2: Child’s Personal Information

Section 3: Additional Children’s Personal Information

Section 4: Secondary Contact

Street Address (Topamax)

Section 5: Mother’s Medical Information

Section 6: Pharmacy Information

Section 7: First Trimester Details

Section 8: Second Trimester Details

Section 9: Third Trimester Details

Section 10: Additional Information at Time of Birth

Section 11: Child’s Diagnosis Information

Section 12: Primary Diagnosis Providers - If YES to Diagnosis in Qualification

Street Address 4 (Topamax)

Telephone number to the facility (Topamax)

Section 13: Treatment Providers - If YES to Autism Diagnosis in Qualification

Section 14: Individualized Education Plan Details- If YES to IEP in Qualification

Part 7: APAP Additional Questions

Section 1: Mother’s Personal Information

Section 2: Child’s Personal Information

Section 3: Additional Children’s Personal Information

Section 4: Secondary Contact

Section 5: First Trimester Details

Where did you buy each product from? (APAP)

IF MULTIPLE PRODUCTS: Approximately what % did you take of each product? For example, 50% Tylenol and 50% Safeway Signature Care Acetaminophen. (APAP)

Section 6: Second Trimester Details

Section 7: Third Trimester Details

Section 8: Additional Information at Time of Birth

During your pregnancy with this child, what states did you purchase/take the acetaminophen-containing product in? (APAP)

Section 9: Child’s Diagnosis Information

Section 10: Primary Diagnosis Providers - If YES to Autism Diagnosis in Qualification

Name of the FIRST facility where diagnosis occurred (APAP)

Name of the physician or medical professional (APAP)

Section 11: Treatment Providers - If YES to Autism Diagnosis in Qualification

Section 12: Individualized Education Plan Details- If YES to IEP for Autism in Qualification

Section 13: Early Intervention Services Details- If YES to Early Intervention for Autism in Qualification

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