NHDHHS Autism Spectrum Disorder Registry Reporting Form
All fields are required.
PATIENT INFORMATION
 
 Patient's first initial of last name:  Last 4 digits of Patient's SSN#:
 
 Birth Date (mm/dd/yyyy):  Gender:
 
 Residence at Birth:
(City/Town)
(State)
 
 NH Residence at time of diagnosis:
(City/Town)
(State) New Hampshire
 
 Ethnicity/Race:




Other (please Specify): 
 
DIAGNOSIS INFORMATION
Please select either DSM-V or ICD-10 but not both
 
 DSM-V  
   
   Autism Spectrum Disorder
   
 ICD-10  
   
   Diagnosis:
   
DATE OF DIAGNOSIS (mm/dd/yyyy):
 
REPORTER INFORMATION
 
 Name (First, MI, Last):
 
 Degree (select one):



Other (please Specify): 
 
 License Number:
 
 Email or Postal Mail Address:
 
 
If you have any questions please feel free to contact Peggy Sue Greenwood at:
Phone: 1-800-852-3345, Ext. 5034 (NH only) or (603) 271-5034 Fax: (603) 271-5166

New Hampshire Department of Health and Human Services
129 Pleasant Street | Concord, NH | 03301-3852


copyright 2013. State of New Hampshire