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Referred by
Review/Follow up Consultation Form
Social Relationship And Reciprocity
Has poor eye contact*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Lacks social smile*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Lacks social interaction skills(eg. Prefers to be alone)*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Is in his/her own world*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Is unable to develop peer relationships*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Always play alone & engages in repetitive play activities*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Is unable to share enjoyment*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Emotional Responsiveness
Shows exaggerated emotions*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Self stimulates*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Lacks fear of danger*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Excited or Agitated without any reason*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Shows Hyperactivity or Restlessness*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Shows Excessive anger*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Engages in self harming*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Speech – Language and Communication
Speech and language delay*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Produces unusual noises*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Unable to use non - verbal communications*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Repeats words*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Cannot express needs*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Unable to initiate or sustain conversation with others*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Uses meaningless words*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Does not understand basic instructions*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Sensory Aspects
Does not respond to his/her name*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Stares into space for long time*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Has difficulty in tracking objects*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Has unusual eye position or movements*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Does not recognise pain*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Responds to objects or people only by touching, smelling or licking*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Lacks consistent attention and focus
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Excessive fear of noises/ covers ears frequently*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Flap Hands repeatedly*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Head Banging*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Walks on tip toes*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Does not play with toys appropriately*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Shows delayed responses*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Spins in circle repeatedly*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Only eats same food always*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Like to have same routine always*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Irregular sleep pattern*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Intermittent Cold/ Fever/ Allergies*
Never - 0
Rarely - 1
Sometimes - 2
Frequently - 3
Always - 4
Inpatient treatment required
Yes
No
Online Video Consultation needed
Yes
No
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