PatientInfo

Is child enrolled in school

Yes

Intervention plan

Consanguinity

No

Neck holding

Achieved

Food preferences

Mixed

HR

Neuropsychiatric condition

No

Place of Birth

Institutional

Hospitalization

No

Tactile

PatientId

ff65f829-b95f-47f6-ae15-8d4232f16c0e

FollowUpId

00000000-0000-0000-0000-000000000000

Child's Name

Kanha Baretha

Age

11 Year 7 Month 18 Days

Gender

Male

DOB

2014-11-22

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

Number of siblings

2

Details of siblings (Age and sex)

1-14yf, 2- 8ym

Address

Sumaouli, Joura

Contact

9770276485

Referred By

Doctor

Informant

Father

Chief concerns

Duration of symptoms

Concerns noticed by school (if any)

Strengths of child

Eye contact

Sustained

Interaction

Quality of Interaction

age-appropriate

Repetitive behaviors (RRBs)

If yes- Details

Handflapping

Patterned behavior or activities

If yes- Details

Others

Details:

Impression

ID

Hopes from the consultation