HomeoConsult R&D

Case Analysis Questionnaire PURPOSE OF THIS FORM : The information provided by you
will be used only for the purpose of assisting Homeopathic
Dr.
Dr. Vaknalli’s,
Vaknalli’s, Homeopathic
Homeopathic treatment
treatment centre
centre for
for chronic
chronic
ailments
ailments
physicians Dr. Anish Vaknalli to arrive at a suitable remedy
for your ailment.

AUTISM, ADD, ADHD, BEHAVIORAL DISORDER EVALUATION FORM

(ADAPTED FROM ATEC FORM OF AUTISM RESEARCH INSTITUTE, SD, CA, USA)

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CONFIDENTIAL DATA WILL BE STORED IN OUR PASSWORD PROTECTED DATABASE

Today’s Date: 22/04/2017

First Name: AFRAH Last name: MARYAM

Age: 4 Sexes: Female

Address: Mohammed Farhan,H-No 10-4-771/8,Flat No 203,Syed Enclave,Opp New

Tulasi High School,Sri Ramnagar Colony,First Lancer,MasabTank,Hyderabad 500028

Phone Number: 7093738565

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Copyright © 2007 Dr. Anish Vaknalli | HomeoConsult Research & Development:
Jain Chambers, S.V. Road, Bandra (W), Mumbai 400050, INDIA. Help Line: 0091-9820190203 Email: ask@homeoconsult.com
Your premier Homeopathic treatment centre since 1970's | Over 60000 cases documented | Serving patients in over 100 countries
www.homeoconsult.com
Speech/Language/Communication Analysis | Tick the appropriate box
(N) Not true
(S) Somewhat true
(V) Very true

N S V
Knows own name
Responds to ‘Stop’ or ‘Come’ or ‘No’
Follows some commands
Can use one word at a time (Eat, Water, Yes, No etc)
Can use two words at a time (Come here, go out etc)
Can use three words at a time (Give me more, want more food)
Can use sentences with 4 or more words
Knows 10 or more words
Explains what he/she wants
Asks meaningful questions
Speech tends to be meaningful/relevant
Often uses several successive sentences
Carries on fairly good conversation
Has normal ability to communicate for his/her age

Sociability
(N) Not true
(S) Somewhat true
(V) Very true

N S V
Seems to be in a shell – cannot reach him/her
Ignores other people
Pays little or no attention when addressed
Uncooperative and resistant
No eye contact
Prefers to be left alone
Shows no affection
Fails to greet parents
Avoids contact with others
Does not imitate
Dislikes being held/cuddled
Does not share or show
Does not wave ‘bye’ bye’
Disagreeable/not complaint
Temper tantrums
Lacks friends or companions
Rarely smiles
Insensitive to others feelings
Indifferent to being liked
Indifferent if parents leave
2
Copyright © 2007 Dr. Anish Vaknalli | HomeoConsult Research & Development:
Jain Chambers, S.V. Road, Bandra (W), Mumbai 400050, INDIA. Help Line: 0091-9820190203 Email: ask@homeoconsult.com
Your premier Homeopathic treatment centre since 1970's | Over 60000 cases documented | Serving patients in over 100 countries
www.homeoconsult.com
Sensory/Cognitive Awareness
(N) Not true
(S) Somewhat true
(V) Very true

N S V
Responds to own name
Responds to praise
Looks at people and animals
Looks at pictures and TV
Does coloring and drawing
Plays with toys appropriately
Appropriate facial expressions
Understands stories on TV
Understands explanations
Aware of environment
Aware of danger
Shows imagination
Initiates activities
Dresses self
Curious, interested
Explores
“Tuned in” – Not spacey
Looks where others are looking

Health/Behavior
(N) Not a problem
(M) Minor problem
(S) Serious problem

N MS
Bed-wetting
Wets pants, diapers
Soils pants/diapers
Diarrhea
Constipation
Sleep disorder
Eats too much or too little
Extremely limited diet
Hyperactive
Lethargic
Hits or injures self
Hits or injures others
Destructive
Sound-sensitive

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Copyright © 2007 Dr. Anish Vaknalli | HomeoConsult Research & Development:
Jain Chambers, S.V. Road, Bandra (W), Mumbai 400050, INDIA. Help Line: 0091-9820190203 Email: ask@homeoconsult.com
Your premier Homeopathic treatment centre since 1970's | Over 60000 cases documented | Serving patients in over 100 countries
www.homeoconsult.com
Health/Behavior (contd.)
(N) Not a problem
(M) Minor problem
(S) Serious problem

N MS
Anxious/fearful
Unhappy/crying
Seizers
Obsessive speech
Rigid routines
Shouts or screams
Often agitated
Not sensitive to pain
Hooked or fixated on certain objects or topics
Repetitive movements (Rocking, flapping etc)

REMINDER CHECK
 Fill all boxes in detail
 Double check your mailing address
 Forwarded relevant case photos & reports
 Signup for the recommended treatment plan

EMAIL THIS QUESTIONNAIRE TO: ask@homeoconsult.com

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Copyright © 2007 Dr. Anish Vaknalli | HomeoConsult Research & Development:
Jain Chambers, S.V. Road, Bandra (W), Mumbai 400050, INDIA. Help Line: 0091-9820190203 Email: ask@homeoconsult.com
Your premier Homeopathic treatment centre since 1970's | Over 60000 cases documented | Serving patients in over 100 countries
www.homeoconsult.com