PatientInfo

Is child enrolled in school

Intervention plan

Plan 1

Consanguinity

Neck holding

Food preferences

HR

Neuropsychiatric condition

Place of Birth

Hospitalization

Tactile

PatientId

00000000-0000-0000-0000-000000000000

FollowUpId

00000000-0000-0000-0000-000000000000

Child's Name

Savita Saxena

Age

25 Year

Gender

Female

DOB

2001-01-01

Mother’s age (years)

20

Mother’s education

Post Graduate

Mother’s occupation

10

Father’s age (years)

10

Father’s education

Graduate

Father’s occupation

10

Type of family

Joint

Number of family members

5

Number of siblings

4

Details of siblings (Age and sex)

20

Address

Kampoo Gwalior

Contact

98555781

Referred By

Healthcare worker

Informant

1212

Chief concerns

2121

Duration of symptoms

Concerns noticed by school (if any)

Strengths of child

Eye contact

Fleeting

Interaction

Quality of Interaction

age-appropriate

Repetitive behaviors (RRBs)

If yes- Details

Patterned behavior or activities

If yes- Details

Others

Details:

Impression

Hopes from the consultation