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Please fill the form and read the terms and conditions given at the end of the form. By filling
this form we understand that you agree to the terms and conditions
Rating Scale
DATE: 21-10-2019
Address: Near Keshav Bal school Near New Jain Mandir Dhonga Road
Tikamgarh M.P
Mobile:-………8085164806………………...Email:-
……rajshribundela86@gmail.com…………………………………………………………………
1. Give details Gestational history ( complications during pregnancy )
2. Were there any Complications during delivery, if yes , please give details.
4. Development History –
Devyani was looking normal initially .She did not respond on name from start but she was active
dances on songs say few words in age 8 months like "achha hai" "jai jai" Papa Mumma but not regularly
many times as per her mood .She grew her tooth late by 9 months .Crawl by 8 months and crawling was
not much she started walking by 1 year on her birthday she walked properly . She remain alone at home
because I am working and I have a tight schedule of 9 to 6. She remained with her grand mother my
mother in law and her father also look after till he went to his work place as he is a businessmen and he
has flexible timing . She drink only milk till 1 year and then cow's milk till 18 months .At this time she was
not saying anything meaningfully she remained aloof and alone looking sad and in her own thoughts .we
got worried .and when we went for check up doctor said she is autistic .from mild to medium .
From August 2018 to April 2019 allopathic medicines were given .then after we
switched to homeopathic medicines.
TESTS:
Not true rarely true somewhat true often True Health Physical behavior Value
0 1 2 3 The child does bedwetting 1
0 1 2 3 The child wets pants and diapers 1
Not true rarely true somewhat true often true Sensory and Cognitive awareness Value
0 1 2 3 The child does not responds to own name 3
0 1 2 3 The child does not responds to praise 3
0 1 2 3 The child does not looks at people and animals 3
0 1 2 3 The child does not looks at pictures 0
0 1 2 3 The child does not coloring and art 3
0 1 2 3 The child does not play with toys appropriately 3
0 1 2 3 The child does not shows appropriate facial 3
expressions
0 1 2 3 The child does not understand stories on TV 3
0 1 2 3 The child does not understand explanations 3
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3.Sociability
In the section named ‘value’ write down the number 0, 1 2, 3 corresponding to (Not true, rarely true, somewhat true, often
true) the severity of the symptoms
Not true rarely true somewhat true often true Sociability value
0 1 2 3 The child seems to be in a shell – you cannot reach 3
him/her
0 1 2 3 The child ignores other people 3
0 1 2 3 The child pays little or no attention when 3
addressed
0 1 2 3 The child is uncooperative and resistant 3
0 1 2 3 The child has no eye contact 2
0 1 2 3 The child prefers to be left alone 1
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Not true rarely true somewhat true Often true Speech and Communication value
0 1 2 3 The child does not knows his name 0
0 1 2 3 The child does not responds to no or stop 0
0 1 2 3 The child cannot follow commands 2
0 1 2 3 The child cannot use one word 3
0 1 2 3 The child cannot use 2 word at a time 3
0 1 2 3 The child cannot use 3 word at a time 3
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Total
Your child’s Autism rating is Total the value in all the four sections 177
(health and behavior , sensory& cognitive awareness,
sociability ; speech and communication )
TERMS OF USE
If the patient has made a payment for 1 year plan on 1st January 2014
and the medicines are dispatched on 5th January ,then we will
consider the treatment to be applicable from 12th January 2014 to 12th
January 2015 i.e one week after we have dispatched the medicines.
If there are any lapses in treatment and medicines, then the clinic or
the concerned doctor will not be held responsible for the same. The
patient cannot claim for any extra or remaining medicines or
appointments after the duration of the opted plan has exhausted.
Kindly ask for a walk in appointment at least 3 weeks in advance as
we generally have a waiting period of 2-3 weeks for the follow-up
patients.
The parents have to keep a track for the telephonic appointments to
be availed or when the medicines have to be ordered as they will not
be receiving any telephonic reminder for the same. The parents do
receive an automated e-mail for the reminders but sometimes the e-
mail may bounce back because of some technical reasons.
IMPORTANT INSTRUCTIONS
Please attach all the medical reports of the child with this form or e-mail us
separately.(MRI,EEG,BERA test ,Blood tests)
According to our experience in treating Autism cases we have seen that
certain autism cases have responded very well to the homeopathic
medicines. But this should not be misconstrued that we are claiming to
cure Autism.
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