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Clinical History Form - Autism - Child

If you wish to be considered for treatment of regressive autism in a child with Throne’s Stem Cell Educator Therapy, please submit the following information

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Parent/Guardian's Relationship To The Child

Child's Gender
Was There A Time When The Child's Development Seemed To Suddenly Regress (Regressive Autism)?
Is There A Family History Of Autism?

Movement/Physical Development Age - Find the oldest set of milestones for which your child fulfills a majority of the criteria

Movement/Physical Development Milestones (Age Two Months) Holds head up when on tummy
Movement/Physical Development Milestones (Age Four Months)
Movement/Physical Development Milestones (Age Six Months)
Movement/Physical Development Milestones (Age Nine Months)
Movement/Physical Development Milestones (Age Twelve Months)
Movement/Physical Development Milestones (Age Fifteen Months)
Movement/Physical Development Milestones (Age Eighteen Months)
Movement/Physical Development Milestones (Age Twenty Four Months)
Movement/Physical Development Milestones (Age Thirty Months)
Movement/Physical Development Milestones (Age Three Years)
Movement/Physical Development Milestones (Age Four Years)
Movement/Physical Development Milestones (Age Five Years)

Assessment For Typical Signs of Autism

Social Interaction Difficulties

Extent Of Eye Contact
Extent Of Understanding Social Cues
Extent Of Interest In Sharing Experiences Or Emotions
Extent Of Interest In Sharing Experiences Or Emotions

Communication Challenges

Delayed or absent language development
Extent of unusual use of language, such as echolalia (repeating words or phrases)
Ability To Understand Or Use Non-verbal Communication, Such As Gestures
Ability To Express Needs Or Wants Clearly

Repetitive Behaviors And Interests

Insistence On Routines Or Rituals
Range Of Interests Or Obsessions
Repetitive Movements, Such As Hand Flapping Or Rocking
Hyperfocus On Specific Objects Or Activities

Other Symptoms Of Autism

Unusual sensory sensitivities to sounds, lights, or textures
Difficulty With Changes In Routine
Unusual Reactions To Emotions Or Experiences
Unusual Anxiety Or Hyperactivity

If the child is between the ages of 16 and 30 months, please answer these screening questions from M-CHAT-R

1. If you point at something across the room, does your child look at it? (For Example, if you point at a toy or an animal, does your child look at the toy or animal?)
2. Have you ever wondered if your child might be deaf?
3. Does your child play pretend or make-believe?
4. Does your child like climbing on things?
5. Does your child make unusual finger movements near his or her eyes?
6. Does your child point with one finger to ask for something or to get help? (For Example, pointing to a snack or toy that is out of reach)
7. Does your child point with one finger to show you something interesting? (For Example, pointing to an airplane in the sky or a big truck in the road)
8. Is your child interested in other children? (For Example, does your child watch other children, smile at them, or go to them?)
9. Does your child show you things by bringing them to you or holding them up for you to see — not to get help, but just to share? (For Example, showing you a flower, a stuffed animal, or a toy truck)
10. Does your child respond when you call his or her name? (For Example, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?)
11. When you smile at your child, does he or she smile back at you?
12. Does your child get upset by everyday noises? (For Example, does your child scream or cry to noise such as a vacuum cleaner or loud music?)
13. Does your child walk?
14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her?
15. Does your child try to copy what you do? (For Example, wave bye-bye, clap, or make a funny noise when you do)
16. If you turn your head to look at something, does your child look around to see what you are looking at?
17. Does your child try to get you to watch him or her? (For Example, does your child look at you for praise, or say “look” or “watch me”?)
18. Does your child understand when you tell him or her to do something? (For Example, if you don't point, can your child understand “put the book on the chair” or “bring me the blanket”?)
19. If something new happens, does your child look at your face to see how you feel about it? (For Example, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?)
20. Does your child like movement activities? (For Example, being swung or bounced on your knee)
Does The Child Have Any Of These Other Autoimmune Disorders? Check All That Apply:

Immunization History - Enter the dates for all immunizations the child has had, enter "Unsure" or "None" if appropriate

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