Paediatric Case Taking

DEVELOPMENT CENTRE FOR CHILDREN WITH AUTISM/ADHD/MR/CP

PRE-ASSESSMENT-

Reason
for referral

Other
agencies involved

Mother
concerns

Home
language

Nationality

Date
of birth

HISTORY BY MOTHER-

BIRTH HISTORY:

Delivery- normal/caesarean

Baby had cried immediately after
birth Yes/No

Cry of baby Loud/Moderate/Feeble

Birth weight

Cyanosis Present/Absent

PAST MEDICAL HISTORY:

0-7 days (neonate illness)

                                                8
days – 1 month

                                                1
month – 1 year

                                                1
year onwards

VACCINATION GIVEN:

FAMILY COMPOSITION:

FAMILY HISTORY:

SOCIAL HISTORY:

 

DEVOLOPMENT HISTORY

DEVELOPMENT MILESTONES

Development milestones in the
first two year of life

Milestones

Patient’s age of
attainment(months)

Average age of attainment(months)

Developmental implications

GROSS MOTOR

Head steady in sitting

 

2.0

Allows more visual interaction

Pull to sit, no head lag

 

3.0

Muscle tone

Hands together in midline

 

3.0

Self –discovery

Asymmetric tonic neck reflex gone

 

4.0

Child can inspect hands in midline

Sits without support

 

6.0

Increasing exploration

Rolls back to stomach

 

6.5

Truncal flexion, risk of falls

Walks alone

 

12.0

Exploration, control of proximity
to parents

Runs

 

16.0

Supervision more difficult

FINE MOTOR

Grasps rattle

 

3.5

Object use

Reaches for objects

 

4.0

Visuomotor coordination

Palmar  grasp tone

 

4.0

Voluntary release

Transfers object hand to hand

 

5.5

Comparison of objects 

Thumb-finger grasp

 

8.0

Able to explore small objects

Turns pages of book

 

12.0

Increasing autonomy during book
time

Scribbles

 

13.0

Visuomotor coordination

Builds tower of two cubes

 

15.0

Uses objects in combination

Builds tower of six cubes

 

22.0

Requires visual, gross, and fine
motor coordination

COMMUNICATION AND LANGUAGE

Smiles in response to face , voice

 

1.5

Child more active social
participant

Monosyllabic babble

 

6.0

Experimentation with sound,
tactile sense

Inhibits to “No”

 

7.0

Response to tone(non verbal)

Follows one step command with
gesture

 

7.0

Non verbal communication

Follows one step command without gesture

 

10.0

Verbal receptive language(e.g.
give it to me)

Speaks first real word

 

12.0

 

Speaks 4-6 words

 

15.0

Acquisition of object and personal
names

Speaks 10-15 words

 

18.0

Acquisition of object and personal
names

Speaks two-word sentences(e.g. mommy
shoe)

 

19.0

Beginning grammaticization,
corresponds with 50+ word vocabulary

COGNITIVE SKILLS

Stares momentarily at spot where
object disappeared

 

2.0

Lack of object permanence(out of
sight, out of mind)(e.g. yarn ball dropped)

Stares at own hand

 

4.0

Self-discovery, cause and effect

Bangs two cubes

 

8.0

Active comparison of objects

Uncovers toy(after seeing it
hidden)

 

8.0

Object permanence

Egocentric pretend play(e.g.
pretends to drink from cup)

 

12.0

Beginning symbolic thought

Uses stick to reach toy

 

17.0

Able to link actions to solve
problems

Pretend play with doll(gives doll
bottle)

 

17.0

Symbolic thought

 

FEEDING HISTORY:

SELF CARE:

SLEEP:

COMMUNICATION:

PLAY:

PREGNANCY HISTORY

1st Trimester

2nd Trimester

3rd Trimester

MEDICAL ASSESSMENT

Current development status:

Hand skills:

Hearing and Language:

Bowel movement:

Socialization:

Central Nervous System:

HOMOEOPATHIC HISTORY

Appetite:

Craving:

Food/drink

agg/amel:

Thirst:

Urine:

Perspiration:

Sleep:

Physical
sensitivity:

Veg/Non-veg:

Aversion:

Stool:

Physical sensitivity:

SUN

NOISE

LIGHT/DARKNESS

ODOUR

TIGHT
CLOTHING

MOTION

 

SENSES:

TOUCH

SMELL

TASTE

VISION

HEARING

 

 

MENTAL GENERALS:

 

 

IMPRESSION & EVALUATION:

 

RUBRICS TAKEN:

 

REMEDY FOLLOW UP CRITERIA:

 

 

 

 

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