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Autism History
Home
Autism History
Autism History
Quick Prescriber For Autism
Name *
Gender *
Male
Female
Other
Date of Birth *
Complete Address
Email id
Mobile No.(Father/Mother) *
Landline No(If Any)
Father's Name
Father's Occupation
Mother's Name
Mother's Occupation
Name of School
Reference from
Since how long child has been diagnosed with *
-Select-
1-2 yrs
Less than 5yrs
Above 5yrs
More than 10yrs
How was it diagnosed/how did you came to know about it? *
-Select-
Delayed milestones
No response when called
No eye contact
Less understanding
Repeatative behaviour
Restless
Any Other
Treatment Taken *
-Select-
Occupational Therapy
Speech Therapy
Stem Cell Therapy
Allopathy
Ayurvedic
Homoeopathy
Any Other
Result Of Treatment Taken *
-Select-
Little Relief
No Change / No Relief
Much Better
Birth History
(Please Give Exact Details, This section is very Important)
Birth Weight *
-Select-
Underweight(1.5 -2.5kg)
Normal( 2.5 - 4kg)
Overweight (4 kg and above)
Teething( What age did
1st Tooth
erupt) Please Give Exact Age (Year)
Did the Child Suffer from any Complaints During Teething?
(Eg. Loose Motion/Fever)Give Details
Talking (When Did the child speak 1st clear word.
Eg mama, papa, dada)
Speech Is *
-Select-
Clear
Monosyllabus
2-3 words Only
Speaks but not clear
Babbling Only
Stammering
Walking( When did the child start walking) *
-Select-
With Support
Without Support
Delivery *
-Select-
Normal/Vaginal
Forcep
Vaccum
Cesarean
Was there any History of Injury to child
-Select-
Head
Body
Spine
What was the condition of the child after injury
-Select-
Conscious
Unconscious
Vomitting
No complaints
What was the effect of vaccination on the child
-Select-
Fever
Epilepsy /Siezures
Skin issues
Any hospitalistion
Any behavioural or physical change
Any Other
Did the child have any problems after birth
-Select-
Lot of Hair on body
Jaundice
Cyanosis
Did he / she cry immediately after birth
Did he / she swallow stool at birth
Any Other
Where the reflexes of the child normal at birth
-Select-
Yes
No
Birth Defects
-Select-
Cleft Palate
Cleft Lip
Ears Deformed
Nose Deformed
Arms
legs
hands
feets
trunk deformity
Spine Defect
Any other
Any infection did the child suffer or had after birth.(please mention it if any)
Mother's history
(please mention the exact details)
Was the mother happy with the pregnancy *
-Select-
Yes
No
If No did she tried doing anything or tried aborting it *
-Select-
By taking pills
Tried Aborting
Didn't Try Aborting
Was the mother detected or suffered from any illness during pregnancy(please mention the details)
Any Stress During Pregnancy( Negative emotions, fight, rejection / Shock or any other) (Give Details)
Any medication taken during pregnancy?
Any problem after taking the medicines?
Does your child have any of the Following features
Moles / wart
Birth Mark
Lots Of hair on body (chest / back / face / hands / legs)
Sweating palms / soles
White spots on nails
Wrinkled Skin
Marasmus
Wasting Of muscle
Abdomen Distension / Bloated
Overweight for age
Underweight for age
Too short for age
Too tall for age
Any Other
Child Behaviour
Understanding *
-Select-
Very Poor (Just cant get it)
Moderate (Inability to understand abstract concept)
Normal
Reaction of child, when he/she wants something
-Select-
Pulls hands
Points out
Says Verbally
Uses some other gestures
Eye contact
-Select-
Poor/Nil
Normal
Resolved now
For very short time
When called, What is the response
-Select-
Doesn`t respond at all
Gives eye contact but doesn`t answer or talk
Responds Normally
Resolved now - but earlier had issues
Any Other
Physical General
Appetite
-Select-
Normal
Increased
Decreased
Easy satiety
Thirst
-Select-
Normal
Thirstless
Sip by Sip
Thirst for large quantity
Prefers which water mostly
-Select-
Cold
Normal
Warm
Urine(please mention complaint if any)
Stool
Clear
Habit
Nail Biting
Yes
No
Jumping
Yes
No
Clapping
Yes
No
Flapping of hands
Yes
No
Shaking legs
Yes
No
Laughing Unnecesscarily
Yes
No
Teeth Grinding
Yes
No
Habit of Chalk /Mud / Licking walls
Yes
No
Bedwetting
Yes
No
Thumbsucking
Yes
No
Touching Things
Yes
No
Hugging Everyone
Yes
No
Kissing Everyone
Yes
No
Playing with private parts
Yes
No
Roaming naked in house
Yes
No
Clinging to mother / Wants mother around always
Yes
No
Arranging objects in a line
Yes
No
Spitting
Yes
No
Staring At objects
Yes
No
Turning round & round
Yes
No
Making Noise
Yes
No
Walking on toes
Yes
No
Watching the objects which are moving round and round For eg. Fan
Yes
No
Imitating
Yes
No
Puts things in mouth
Yes
No
Aloof(his/her own world)
Yes
No
Echolalia(Repeating same words)
Yes
No
Rocking/Moving to and fro
Yes
No
Any other
Desire/Loves
Music
Yes
No
Company
Yes
No
Travelling
Yes
No
Animals
Yes
No
Carried To be
Yes
No
Any other
Aversion(Does not like) or Sensitive to
Light
Yes
No
Company
Yes
No
Being Alone
Yes
No
Looked at
Yes
No
Touch
Yes
No
Noise
Yes
No
Opposite sex
Yes
No
Bathing
Yes
No
Crowd
Yes
No
Hair cut / Nail cut
Yes
No
Any other
Fear(Phobia)
Heights
Yes
No
Dark
Yes
No
Water
Yes
No
Animals
Dog
Reptiles
Snakes
Insects
Birds
Thunderstorm
Yes
No
Light
Yes
No
Narrow places
Yes
No
Strangers
Yes
No
Being alone
Yes
No
Flowers
Yes
No
Speed
Yes
No
Ghost
Yes
No
Crowd
Yes
No
Noise
Yes
No
Any other
Anger
Throws things
Yes
No
Bangs head
Yes
No
Hits Others
Yes
No
Hits himself
Yes
No
Hits himself on head
Yes
No
Spits
Yes
No
Breaks things
Yes
No
Shouts and Shrieking
Yes
No
Cries in anger
Yes
No
Pinching
Yes
No
Biting
Yes
No
Pulling Hairs
Yes
No
Uses Abusive Language
Yes
No
Any other
Weeping / Cries
Cries when alone
Yes
No
Cries in front of others
Yes
No
Cries without reason / unnecessarily
Yes
No
Crying alternate with Laughing
Yes
No
Any other
Yes
No
General Behaviour
Obstinate
Yes
No
Inquisitive
Yes
No
Talkative
Yes
No
Concentration Difficult
Yes
No
Hyperactivity
Yes
No
Lazy
Yes
No
Music
Dances on hearing music
Afraid of music / loud noise
Becomes quiet on hearing Music
Destructive
Yes
No
Revengeful (Will he/she hit back if someone hits?)
Yes
No
Jealousy (Sibling Jealousy or any other)
Yes
No
Religious (God loving / God fearing)
Yes
No
Irritability
Yes
No
Suspicious / Doubtful
Yes
No
Teasing others and enjoys doing that
Yes
No
Teased by others
Yes
No
Any Other
Immunity
Has repeated cold / cough
Skin Troubles
Stomach Troubles
Constipation
Loose motion
Any Other
Reading
I am a poor reader
I do not like reading
I make mistakes when reading like skiping words or lines
I read the same lines twice
I have problems remembering what I read even though I have read all the words
I reverse letters when I read(b/d,p/q)
I switch letters in words when reading (such as god and dog)
My eyes hurt or water when I read
Words tend to blur when I read
Words tend to move around the page when I read
When reading I have difficulty understanding the main idea or identifying important details from a story
Any Other
Writing
I have messy handwriting
My work tends to be messy
I prefer print rather than writing in cursive
My letters run into each other or there is no space between words
I have trouble staying within lines
I have problems with grammar or punctuation
I am a poor speller
I have trouble copying off the board or from a page in a book
I have trouble getting thoughts from my brain to the paper
I can tell a story but cannot write it
Any Other
Body awareness/ spatial relationships
I have trouble with knowing my left from my right
I have trouble keeping things within columns or coloring within lines
I tend to be clumsy, uncoordinated
I have difficulty with eye hand coordination
I have difficulty with concepts such as up, down, over, under
I tend to bump into things when walking
Oral expressive language
I have difficulty expressing myself in words
I have trouble finding the right word to say in conversations
I have trouble talking around a subject or getting to the point in conversations
Receptive language
I have trouble keeping up or understanding what is being said in conversations
I tend to misunderstanding people and give the wrong answers in conversations
I have trouble understanding directions people tell me
I have trouble telling the direction sound is coming from
I have trouble filtering out background noises
Maths
I am poor at basic math skills for my age (adding, subtracting, multiplying, dividing)
I tend to switch numbers around
I make careless mistakes in maths
I have difficulty with word problems
Sequencing
I have trouble getting everything in the right order when I speak
I have trouble telling time
I have trouble using the alphabet in order
I have trouble saying the months of the year in order
Abstraction
I have trouble understanding jokes people tell me
I tend to take things too literally
Submit
