All data will be treated in the strictest confidence

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Health Questionnaire for the AS Partner

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If you wish to remain anonymous please leave these questions blank.

Your Name:
Your Address:
Your Email:

If you've entered your details above, is it ok for Maxine to contact you in the future about follow up studies? Yes   No

This section is about you.

Sex:	Female   Male
Age:
Highest academic level of achievement:
Occupation:
Have you been diagnosed with Asperger syndrome?:	Yes   No

This section is about your partner.

Sex:	Female   Male
Age:
Highest academic level of achievement:
Occupation:
Is your partner affected by Asperger syndrome?:	Yes   No
If Yes, has your partner been diagnosed with Asperger syndrome?:	Yes   No

This section refers to your relationship.

Marital or Relationship Status:
How many years have you been, or were, with your partner?:
If married, how many years married?:
If separated or divorced, how long have you been apart?:
Have you had any children with your partner?:	Yes   No
If Yes, have any of the children been diagnosed with an Autistic Spectrum Disorder (ASD)?:	Yes   No

If you and your partner have ever been for relationship counselling, please describe the experience you had and the outcomes?

This section refers to your Mental and Physical Health

I believe my MENTAL HEALTH has suffered due to being in this relationship. strongly disagree   disagree   not sure   agree   strongly agree

I believe my PHYSICAL HEALTH has suffered due to being in this relationship. strongly disagree   disagree   not sure   agree   strongly agree

Tick any of the following MENTAL HEALTH symptoms you may have experienced:  Depression  Stress  Self Neglect  Anxiety  Suicidal thoughts  Self-harm  Phobias  Breakdown  Health improved Other  Tick any of the following PHYSICAL HEALTH symptoms you may have experienced:  Eating disorders  Immune Deficiency Disorder  Panic attacks  Insomnia  Skin Disorders  Muscular problems  Fibromyalgia  Chronic Fatigue Syndrome  Exhaustion  Migraine  Weight Gain  Health improved Other

Please add any other comments here.