SYMPTOMS |
INTENSITY OF SYMPTOMS 0-10
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1 |
Facial Expression (During conversation, can you see his/her emotions in the face) |
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2 |
Verbal Communication (How many words can he/she express verbally at any one time and what is the extent of his/her vocabulary) |
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3 |
Eye Contact (During conversation, when calling his/her name, how many seconds is there eye to eye contact) |
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4 |
Confidence Level (Level of confidence and reaction to new or crowded places) |
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5 |
Aggressive Behaviour (Towards others and things that must be in his/her way when he/she wants) |
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6 |
Physical Action (Towards others or himself/herself. Hitting people or himself/herself against walls, how frequent, how long) |
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7 |
Sociability (With parents, kids or strangers, how does he/she react towards others) |
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8 |
Understanding (Towards surroundings or routine daily life) |
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9 |
Interest (Towards kids and adults, any attention towards others) |
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10 |
Alertness (With surroundings, how quick he/she responds to things occurring to them) |
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Please write (0<300 words):
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11 |
Sensory Awareness (Level of awareness to smells, textures and visual changes) |
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12 |
Hyperactivity Degree (Is he/she moving non-stop and when are they usually active) |
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13 |
Writing (Ability to write for age level) |
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14 |
Reading (Ability to read for age level) |
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15 |
Speaking (Ability to speak to others, volume of voice and do they speak to themselves) |
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16 |
Conversation with others (Starting a conversation, extent of word exchange) |
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17 |
Obedience (When given an order, what is his/her response, how many times are they asked to do something before the task is completed) |
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18 |
Interest in Sharing (With others, enjoy and sharing with others, ask people to see what they have or have found) |
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19 |
Repetitive Words (How frequent do they repeat words or do they ask the same question or say the same words or phase again and again) |
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20 |
Repetitive Behavior (When angry, protesting, bored or playing in same pattern) |
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Please write (0<300 words):
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21 |
Liking particular things (Holding it all the time or keeping it in a safe place) |
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22 |
Laughing (Likes to laugh for no apparent reason) |
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23 |
Afraid of things (One cannot see or hear but they can. Things he/she intensely dislikes) |
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24 |
Obsessive of Sequence of Events (In his/her position, event must follow the same order) |
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25 |
Willingness to Play (When asked to play, he will easily join and then refuse, or not respond) |
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26 |
Share toys with others (With siblings or unknown kids) |
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27 |
Fighting back for toys (How aggressive will he/she fight or just let go of toy to siblings or other kids) |
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28 |
Walking (Does he/she walk a lot, normally) |
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29 |
Running (Does he/she run a lot, normally) |
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30 |
Throwing an Object without reason (Like to throw something if upset or happy, without any other reason) |
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Please write (0<300 words):
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31 |
Jumping without reason (Jumping if excited or angry) |
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32 |
Hand, Finger flapping or twisting (When/how frequent) |
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33 |
Response to calling their name (Immediately will respond or ignore, how many times to call he/she before responding ) |
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34 |
Asking for Food or to go to the Toilet (when hungry, do they ask for food. Do they ask to go to toilet before it is too late and are they toilet trained) |
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35 |
Arguing for right things (Know when is right or wrong to start to argue) |
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36 |
Screaming without reason (When, how many times per day) |
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37 |
Crying without reason (When or how frequent) |
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38 |
Mother on milk during pregnancy |
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39 |
Music (How do they respond to music) |
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Please write (0<300 words):
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40 |
Breast feeding after birth till how many months |
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41 |
Mother on milk during pregnancy |
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42 |
Vitamin or Folic Acid during pregnancy |
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43 |
Mother has other complication during pregnancy |
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44 |
Health events occurring during pregnancy |
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45 |
From birth to what age on formula or normal milk |
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46 |
Other medical problem of child |
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47 |
Does the child have Seizures or Fits? How many seconds each time, how many episodes at any one period of time |
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48 |
Allergies |
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49 |
Food Allergies |
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50 |
Phlegm / Mucus |
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51 |
G6PD |
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Please write (0<300 words):
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