PatientInfo

Is child enrolled in school

Yes

Intervention plan

Consanguinity

No

Neck holding

Food preferences

Mixed

HR

Neuropsychiatric condition

No

Place of Birth

Institutional

Hospitalization

No

Tactile

PatientId

6ab1fb9f-e359-4870-ae0c-e99bb405d3b0

FollowUpId

00000000-0000-0000-0000-000000000000

Child's Name

Animesh

Age

9 Year 10 Month 2 Days

Gender

Male

DOB

2016-11-05

Mother’s age (years)

Mother’s education

Mother’s occupation

Father’s age (years)

Father’s education

Father’s occupation

Type of family

Joint

Number of family members

6

Number of siblings

1

Details of siblings (Age and sex)

6-year-old male

Address

Govindpuri

Contact

7049235989

Referred By

Informant

Parents

Chief concerns

Academic concerns

Duration of symptoms

Concerns noticed by school (if any)

Strengths of child

Social interaction

Eye contact

Sustained

Interaction

Avoids playing with peers

Quality of Interaction

age-appropriate

Repetitive behaviors (RRBs)

If yes- Details

Patterned behavior or activities

If yes- Details

Others

Details:

Impression

? SLD

Hopes from the consultation