Assessment Format for Autism Spectrum Disorders

7/23/2019 Assessment Format for Autism Spectrum Disorders

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ASSESSMENT FORMAT FOR AUTISM SPECTRUM DISORDERS

Date of evaluation:

Demographi !ata: Name-

Age:

Sex:

Informant: "

Chief Complaint#:

Age of on#et$ Di#a%ilit& fir#t note!: "

'i#tor&:"(irth 'i#tor&:

Prenatal illness of the mother-

H/O abortion/ miscarriage before pregnancy-

Duration of pregnancy: (ull term/ preterm!-

"ype of #eli$ery: (Normal/ %&' section/ orceps!-

irth cry: ()mme#iate/ Delaye#!

irth *eight: (H/O +, or o$er*eight!-

H/O birth inury if any-

H/O fe$er/sei.ures/aun#ice other #isor#ers-

"reatment #etails-

0other1s mil2/ H/O oromotor abnormalities at infancy-

Developmental 'i#tor&:

0otor (Hea# control3 roll o$er3 cra*ling3 sitting3 stan#ing3 *al2ing!-

H/O Speech/ motor #elay if any-

Family History: Number of family members in family-

irth or#er of the chil#-

Presence of consanguinity-

Age of parents an# siblings-mother age-3father age-

H/O similar illness in the family-

"ype of amily: (Nuclear/4oint/ Separate#!-

Treatment 'i#tor& :Present an# past therapy / treatment chil# un#er*ent-



E!uational 'i#tor&:

5#ucational status of the parents-

5#ucational status of the chil#-

On O%#ervation:Postures/ physical abnormality/ sensory signs/ play s2ills/ others

&hil# li2es to hol# small piece of threa#3 paper etc

5noys ma2ing soun# through mouth6

+i2es to hug an# touch others

Pla& 'i#tor& ) evaluation:A$ailability of play space an# toys-

"ype of moti$ation ()ntrinsic/extrinsic!-Ability to manipulate toys

Play stage (solitary/ parallel/ group cogniti$e #e$elopmental stages!-

Speeh an! language:"0o#e of communication - speech/ sign/ AA&-

7ecepti$e language s2ills-

5xpressi$e language s2ills- absent

On E*amination:

Motor #+ill#:

,ro## motor:8ait pattern-

Stair climbing-

4umping/ Hopping-

Supine flexion-

Prone extension-

(alane ) oor!ination #+ill#"

59uilibrium reactions / protecti$e extension-

Stan#ing balance (Static #ynamic!-

Sitting balance (Static #ynamic!-

/+ symmetrical Asymmetrical coor#ination- b/l symmetrical

5ye han# coor#ination-

Praxis (P/O any 2in# of #yspraxia!-

Imitation #+ill#:"

)mitates gross motor mo$ements *ith se9uence an# repetition

imitates oral motor mo$ement



)mitates bloc2 pattern-

)mitates action paire# *ith soun#s-

)mitates $erbal responses -

Fine motor #+ill#"

8rasp: 0ass/ cylin#rical/ s9uare/ Hoo2-present

7each: (At all si#es in stan#ing/ cross leg long leg sitting!-

0i#line crossing -

7elease-

Pinch: (tripo#/ pulp to pulp/ tip to tip!-

In han! manipulation #+ill#: "ranslation (finger to palm!-

7otation (simple/ complex!-Shift ($ertical/ hori.ontal!-

Cognitive Pereptual #+ill#:

Orientation: "ime3 place person )#entification of parents3 family members3

frien#s3 rooms at home/school3 concept of to#ay/ tomorro*/ later/ morning/ noon/

e$ening/ night6-

&omprehension: Ability to follo* comman#s (single step / multi step!-Attention: (;isual / au#itory!-

&oncentration:-

0emory: ;erbal ;isual (short term/ long term!-

Perception: (igure groun#/ colour!

Conept#:

o#y parts (on self others!-

&olour (Sorting to abstract of each!-

Si.e (i#entification to comparison!-

Shape (Sorting to abstract of each!- Number (rote counting number concept!-

-i#ual pereption #+ill# :

;isual trac2ing -

)#entifying similar pictures/ pattern of #esigns-

Dot oining-

loc2 #esigning-

Pu..le sol$ing ( <piece3 =piece3 >piece3 etc!-

Design copying-



Soial$ emotional #+ill#:"

Social smile -

5ye contact maintaining an# sustaining-Stranger i#entification-

Stranger fear-

Peer interaction (Spontaneous/ *ith prompt!-

5motional comprehension-

5xpressions of emotion-

As2ing for nee#s-present (non $erbally!

5xpressing li2es an# #isli2es-present non $erbal

As2ing for help-present

Oromotor funtion#:"

Oral sensiti$ity-

Presence of #rooling-

Oral mo$ements/ oral praxis-

iting/ che*ing-

lo*ing/ Suc2ing-

Sipping/ spitting

Shool rea!ine## #+ill#:"

Sitting tolerance-

,aits for turn-

Sustaining an# maintaining peer group-

ollo*s instruction in a group -

Sen#or& Evaluation:"

Stereotypical/ ritualistic beha$iors-

8ra$itational insecurity-

Sleep #isturbances-

Tatile :"Seem o$erly #istresse# *hen ha$ing his hair or fingernails / toenails

cut?-

Ha$e an unusual nee# for touching or a$oi#ing touching certain

surfaces or textures such as blan2ets3 carpets3 or stuffe# toys?-

Disli2e getting his han#s in san#3 finger paint3 paste3 or similar materials?-



Proprioeptive :"Seem #ri$en to see2 acti$ities such as pushing3 pulling3 #ragging3

lifting3 an# umping?-

8rin#s his teeth?-

-e#ti%ular:"See2 an#/or tolerate mo$ement acti$ities such as s*inging3 running3

an# umping an# not seem to get #i..y as rea#ily as others? -

Seem to ha$e trouble sitting upright3 or ten# to slouch *hen at a table

or #es2?-

-i#ual:"

Sensiti$e to or bother by light3 especially bright light (blin2s3 s9uints3cries3 or close eyes!?-

Ha$e trouble fin#ing an obect *hen it is aime# a group of other

things? -

Au!itor&:"Seem highly sensiti$e to noise an# sometimes hear things that other

people #on1t hear? -

Seem o$er*helme# or #istracte# by laughter3 cheers3 or cro*#s of

people spea2ing at the same time3 such as in a restaurant? -

Olfator& $ ,u#tator&:"8ags3 $omit3 or complain of nausea *hen smelling o#ors such as soap3

perfume3 or cleaning pro#ucts?-

+i2e to taste non foo# items such as glue3 paint etc6?-

(ehavior:

@uiet / Normal / O$er-Acti$e/ )mpulsi$e / Aggressi$e / Distractible /

*ants attention / anxious / frien#ly / shy chil# is usually 9uit an# frien#ly but

becomes impulsi$e follo*e# by aggressi$e *hen restricte# from acti$ities *hich

gi$es a##itional tactile stimulation6

(ehavior pro%lem#:

"antrum $ 0ala#apti$e/ inurious beha$iors if any-sho*s tantrums an#

fi#gety *hen *ish is not fulfille#6

AD.#:"



(ru#hing:Opening/ closing tap

Paste on brush

&upping

rushing

7insing/ spitting,ashing/ *iping

Dre##ing:pper bo#y (#onning #offing shirt/ t shirt/ froc2/ inner garments!

+o*er bo#y (#onning #offing pants/ s2irt/ un#er garments!

uttoning/ unbuttoning-

Bipping/ un.ipping-

,earing shoe/ soc2s/ tying shoe lace-

,rooming: (if applicable!-

Eating:Soli#/ semi soli#/ li9ui# (*ith spoon han#!-

Toileting:)n#ication of bo*el/ la##er-

Ability to reach toilet at home in#epen#ently-

Ability to clean self commo#e-

(athing:Dressing/ n#ressing

Pouring *ater

Ability to soap front/ bac2

,ipe

IAD. :"Cno*s common househol# items 2no* its uses an# operations li2e

S*itches / "ele$isions/ +oc2 etc6

Other #peifi i##ue# if an&"

Documents

Assessment Format for Autism Spectrum Disorders