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Welcome to Otika template!
Yesterday
Hello
Profile
Activities
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Patient Info-Digital Prescription & Assessment Format
Demographic Details
Child's Name
Gender
Male
Female
Other
DOB
Age
Mother’s age (years)
Mother’s education
Post Graduate
Graduate
12th
10th
below 10th
Mother’s occupation
Father’s age (years)
Father’s education
Post Graduate
Graduate
12th
10th
below 10th
Father’s occupation
Type of family
Joint
Nuclear
Number of family members
Number of siblings
Details of siblings (Age and sex)
Address
Contact
Referred By
Doctor
Healthcare worker
School
Relative
Camp
Informant
Chief concerns
Duration of symptoms
Concerns noticed by school (if any)
Strengths of child
Current Improvements
Current concerns
Current medications
Investigations done
Interaction history:
Eye contact
Poor
Fleeting
Suboptimal
Sustained
Interaction
Quality of Interaction
age-appropriate
limited
avoids
Behavioral history:
Repetitive behaviors (RRBs)
If yes- Details
Patterned behavior or activities
If yes- Details
Hyperactivity
Inattention
Impulsivity
Defiance
Obsessions and compulsions
Insisting on sameness
Object obsession
Temper tantrums
Stubbornness
Aggression
Self injurious behaviors
Mouthing of objects
Habit behaviors
Enuresis
Encopresis
Bullying others
Being bullied
Lying
Stealing
School refusal
Phobias
Separation anxiety
Lack of motivation
Tics/Movement disorder
Others
Details:
Emotional History:
Lack of emotions
Lack of interest
Irritability
Anxiety
Excessive crying episodes
Mania-like episodes
Others Emotional History Details
Academic Concerns:
Poor scholastic performance
Difficulty in reading
Difficulty in writing
Difficulty in mathematics
Incomplete notebooks
Difficulty copying from the board
Poor recall of learnt material
Inattention in classroom
Poor organisation of school materials
Frequent spelling mistakes
Phonological concerns
Difficulty in comprehension
Illegible handwriting
Oral better than written
Difficulty with mirror images
Difficulty with grammar
Difficulty forming sentences
Difficulty in mathematics operations
Difficulty understanding word problems
Difficulty memorising multiplication tables
Details:
Sensory Concerns:
Tactile
Hypersensitive
Hyposensitive
Auditory
Hypersensitive
Hyposensitive
Fear of loud sounds
Visual
Seeks visuals
Avoids visuals
Proprioception
Seeks pressure
Poor awareness
Vestibular
Seeks movement
Avoids swings
Details:
Birth & Perinatal History
Consanguinity
Yes
No
If yes Degree
1
2
3
Maternal age at conception (years):
Type of conception
Natural
IUI
IVF
Adopted child
High-risk factors in pregnancy:
Chronic hypertension
PIH
Pre-eclampsia
Eclampsia
GDM
Anaemia
Hypothyroidism
Hyperthyroidism
Placenta Previa
Ante partum haemorrhage
Oligohydramnios
Polyhydramnios
Febrile illness
UTI
HIV
Hepatitis B
Hepatitis C
Others:
Natal and Postnatal History
Place of Birth
Home
Institutional
During transportation
Mode of Delivery
NVD
Assisted
LSCS
Indication for LSCS (if applicable)
Gestational Age
Birth Weight
Cry at birth
Cried immediately after birth
Cried after stimulation
Delayed cry
Resuscitation required
Yes
No
Details of Resuscitation
NICU stay
Yes
No
If yes- Duration & Indication
Past History
Hospitalization
Yes
No
Seizures
Yes
No
Others
Past/Current therapies
Past/Current medications
Hearing assessment
Done
Not done
Details
Vision assessment
Done
Not done
Details
Family History
Neuropsychiatric condition
Yes
No
Details (If yes)
Any recent stressful events in family
Yes
No
Details (If yes)
Others
Development History
Gross Motor
Neck holding
Achieved
Not achieved
Age of attainment
Roll over
Achieved
Not achieved
Age of attainment
Sitting without support
Achieved
Not achieved
Age of attainment
Standing without support
Achieved
Not achieved
Age of attainment
Walking without support
Achieved
Not achieved
Age of attainment
Running
Achieved
Not achieved
Age of attainment
Climbing upstairs
Achieved
Not achieved
Age of attainment
Climbing downstairs
Achieved
Not achieved
Age of attainment
Hopping
Achieved
Not achieved
Age of attainment
Standing on one foot
Achieved
Not achieved
Age of attainment
Skipping
Achieved
Not achieved
Age of attainment
Fine Motor
Bidextrous grasp
Achieved
Not achieved
Age of attainment
Unidextrous grasp
Achieved
Not achieved
Age of attainment
Pincer grasp
Achieved
Not achieved
Age of attainment
Scribbling
Achieved
Not achieved
Age of attainment
Drinking from cup
Achieved
Not achieved
Age of attainment
Buttoning / Unbuttoning
Achieved
Not achieved
Age of attainment
Language
Receptive:-
Joint attention
Achieved
Not achieved
Age of attainment
Pointing
Achieved
Not achieved
Age of attainment
Understanding gestures
Achieved
Not achieved
Age of attainment
Following commands
Not following
1-step
2-step
3-step
Expressive:-
Cooing
Achieved
Not achieved
Age of attainment
Babbling
Achieved
Not achieved
Age of attainment
Meaningful words
Achieved
Not achieved
Age of attainment
2 word Phrases
Achieved
Not achieved
Age of attainment
Complete sentences
Achieved
Not achieved
Age of attainment
Narrates events / stories
Details:
Communication & Language Assessment
Non-Verbal Communication Grading: -
Need-based communication
Absent
Emerging
Inconsistent
Consistent
Drag for needs
Absent
Emerging
Inconsistent
Consistent
Joint attention
Absent
Emerging
Inconsistent
Consistent
Pointing
Absent
Attempts
Cued pointing
Inconsistent meaningful pointing
Consistent meaningful pointing
Understanding gestures
Absent
Emerging
Consistent
Following commands (gesture + verbal)
Nil
1-step
2-step
3-step
Answering Questions: -
Able to answer questions
Yes
No
If yes Meaningfully responds to
What
Where
Who
Why
When
How
Echolalia
Absent
Present
Patterned speech
Absent
Present
Social
Social smile
Achieved
Not achieved
Age of attainment
Stranger anxiety
Achieved
Not achieved
Age of attainment
Waving bye bye
Achieved
Not achieved
Age of attainment
Comes when called
Achieved
Not achieved
Age of attainment
Copying parents in tasks
Achieved
Not achieved
Age of attainment
Asking for food and toilet
Achieved
Not achieved
Age of attainment
Response to Name Call
Frequency
5-Always
4-Often
3-Sometimes
2-Rarely
1-Never
Details
Sitting tolerance- (in minutes)
For interaction
For tasks
Details:
ADL Skills (Age-appropriate)
Eating
1. Dependent
2. Started attempting
3. Needs significant assistance
4. Needs minimal assistance
5. Independent
Bathing
1. Dependent
2. Started attempting
3. Needs significant assistance
4. Needs minimal assistance
5. Independent
Toilet training
1. Dependent
2. Started attempting
3. Needs significant assistance
4. Needs minimal assistance
5. Independent
Dressing
1. Dependent
2. Started attempting
3. Needs significant assistance
4. Needs minimal assistance
5. Independent
Undressing
1. Dependent
2. Started attempting
3. Needs significant assistance
4. Needs minimal assistance
5. Independent
Details:
Type of play
Type of play
1. Unoccupied
2. Isolated
3. Onlooker
4. Parallel
5. Associative
6. Cooperative
Outdoor play duration
Details:
Academic History
Is child enrolled in school
Yes
No
Type of school
Regular
Special
Name of School
Grade
Hours spent in school
Board
MP
CBSE
ICSE
Other
Location
Any change of school
Yes
No
Repetition of grade
Yes
No
Additional information
Diet History
Food preferences
Food allergies
Yes
No
Junk food intake
Calorie intake
Protein intake
Sleep History
Total sleep duration (night)
Afternoon nap
Yes
No
Duration of Afternoon nap
Sleep disturbances
Yes
No
If yes description
Daily Screen Time
Duration
Zero
<30 minutes
< 1 hour
< 2 hours
> 2 hours
> 5 hours
Description
Type of screen
Mobile
TV
Tablet
Laptop
Mobile and TV
Examination
a. Vitals:
HR
RR
Temperature
BP
b. Anthropometry:
Weight
Height
Head circumference
BMI
c. General Examination:
Dysmorphology
Neurocutaneous markers
Others
d. CNS:
Higher Mental Function
Consciousness
Orientation
Memory
Speech:
Comprehension
Repetition
Naming
Voice
Judgement
Insight
Perception
Sensory Examination
Touch
Pain
Temperature
2-point discrimination
Stereognosis
Graphesthesia
Proprioception
Cranial Nerves (1–12)
Olfactory nerve
Optic Nerve
cculomotor, Trochlear, Abducent
Trigeminal Nerve
Facial Nerve
Vestibulocochlear Nerve
Glossopharyngeal Nerve
Vagus Nerve
Spinal Accessory
Spinal accessory Nerve
Hypoglossal Nerve
Neuromuscular Concerns
Motor delay
Gross motor
Fine motor
Gross motor and Fine motor
Bulk of muscles
Tone
Normal
Hypotonia
Hypertonia
Power
Deep tandon reflexes
Superficial reflexes
Gait issues
Posture issues
Other
Cerebellar examination
Meningeal signs
Absent
Present
If present details
Oromotor Examination
Drooling
Yes
No
Chewing
Proper
Improper
Swallowing
Proper
Improper
Blowing
Proper
Improper
Sucking
Proper
Improper
Others
Examination summary
e. CVS examination
f. Respiratory System examination
g. Per abdomen examination
Impression
Hopes from the consultation
Advice
Intervention plan
Evaluation
Investigations
Medications
Follow up plan
General recommendation
Zero Screen Time
Physical interactive play
No Junk food
No focus on academics at present
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