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Assessment

Parents / Guardian Name

Email

Code

Phone

Select an Address

Patient Information

Select Gender

Male

Female

Select Age

What therapies are on as of now (Occupational/Speech)

What is his daily schedule (schooling, home studies etc)

What does he do in his personal time and how is he when is he in the company of children and adults.

Hyperactivity: describe what he does in this state

Any fears: Animal, height, sounds, darkness etc

His likes and dislikes in general

His appetite, his preference for food and cravings for any particular taste (salt, spicy, sweet etc)

Any teeth grinding in the day, in anger or at night

Any sexual perversions or fondling of genitals

Describe his sleep pattern and state in sleep

Any destructive habits like breaking things, biting, tearing paper, throwing things, violence etc

How does he calm down when angry

Does he repeat the question before answering

Any head banging, self-hurt or injury

Any dietary changes such as GFCF (Gluten and Casein Free diet) has been started

History of medication – current or past

Any history of reaction to vaccines

Any recurring ailment like chronic colds, cough, skin eruptions, indigestion etc

Any other major illness or test results like epilepsy (EEG for fits), hearing disorder (BERA test) or food intolerance (Gluten sensitivity test)

Knows own name

Not True

Somewhat true

Very true

Responds to "Stop‟ or "Come‟ or "No‟

Not True

Somewhat true

Very true

Can use one word at a time (Eat, Water, Yes, No etc)

Not True

Somewhat true

Very true

Explains what he/she wants

Not True

Somewhat true

Very true

Knows 10 or more words

Not True

Somewhat true

Very true

Ignores other people

Not True

Somewhat true

Very true

Pays little or no attention when addressed

Not True

Somewhat true

Very true

Uncooperative and resistant

Not True

Somewhat true

Very true

No eye contact

Not True

Somewhat true

Very true

Prefers to be left alone

Not True

Somewhat true

Very true

Shows no affection

Not True

Somewhat true

Very true

Fails to greet parents

Not True

Somewhat true

Very true

Avoids contact with others

Not True

Somewhat true

Very true

Does not imitate

Not True

Somewhat true

Very true

Dislikes being held/cuddled

Not True

Somewhat true

Very true

Does not share or show

Not True

Somewhat true

Very true

Does not wave „bye‟ bye‟

Not True

Somewhat true

Very true

Disagreeable/not complaint

Not True

Somewhat true

Very true

Lacks friends or companions

Not True

Somewhat true

Very true

Temper tantrums

Not True

Somewhat true

Very true

Insensitive to others feelings

Not True

Somewhat true

Very true

Insensitive to others feelings

Not True

Somewhat true

Very true

Rarely smiles

Not True

Somewhat true

Very true

Indifferent to being liked

Not True

Somewhat true

Very true

Indifferent if parents leave

Not True

Somewhat true

Very true

Responds to own name

Not True

Somewhat true

Very true

Responds to praise

Not True

Somewhat true

Very true

Looks at people and animals

Not True

Somewhat true

Very true

Looks at pictures and TV

Not True

Somewhat true

Very true

Plays with toys appropriately

Not True

Somewhat true

Very true

Understands stories on TV

Not True

Somewhat true

Very true

Does coloring and drawing

Not True

Somewhat true

Very true

Appropriate facial expressions

Not True

Somewhat true

Very true

Understands explanations

Not True

Somewhat true

Very true

Aware of environment

Not True

Somewhat true

Very true

Shows imagination

Not True

Somewhat true

Very true

Aware of danger

Not True

Somewhat true

Very true

Initiates activities

Not True

Somewhat true

Very true

Dresses self

Not True

Somewhat true

Very true

Explores

Not True

Somewhat true

Very true

“Tuned in” – Not spacey

Not True

Somewhat true

Very true

Wets pants, diapers

Not True

Somewhat true

Very true

Curious, interested

Not True

Somewhat true

Very true

Looks where others are looking

Not True

Somewhat true

Very true

Bed-wetting

Not True

Somewhat true

Very true

Diarrhea

Not True

Somewhat true

Very true

Constipation

Not True

Somewhat true

Very true

Eats too much or too little

Not True

Somewhat true

Very true

Lethargic

Not True

Somewhat true

Very true

Hits or injures others

Not True

Somewhat true

Very true

Sound-sensitive

Not True

Somewhat true

Very true

Sleep disorder

Not True

Somewhat true

Very true

Hyperactive

Not True

Somewhat true

Very true

Hits or injures self

Not True

Somewhat true

Very true

Destructive

Not True

Somewhat true

Very true

Obsessive speech

Not True

Somewhat true

Very true

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