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Pediatric Care Plan
FOR CHILDREN 0-6 YEARS WITH AUTISM SPECTRUM DISORDER
Patient Information
Date of Visit
*
MM slash DD slash YYYY
Primary Pediatrician Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First
Last
Pediatrician Phone #
*
Pediatrician Fax #
Patient Name
*
First
Last
Patient Date of Birth
*
MM slash DD slash YYYY
Patient Age
Patient Gender
*
Male
Female
Parent/Guardian Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Parent/Guardian Emergency #
*
Is this emergency number:
*
Home
Work
Mobile
Physician Name
*
Dr. Denise Aloisio
Dr. Anne Roth
Office Care Coordinator/Social Worker
*
Joanne Dunnigan
Allison Vargovic
Behavior Analyst
(Optional)
Sandy Bendokas
Please check all areas as they relate to your child
Feeding
*
No problems, eats a variety of food
Eats a fair range of food
Eats a limited range of food
Has not increased/changed types of food textures eaten
Sensitive to foods/intolerance
Toileting
*
Fully trained
No interest
In process
No bowel movement on toilet
Abnormal bowel movement (constipated/loose)
Sleeping
*
No problems
Problem with going to sleep
Frequent night time waking
Sensory Aversions
*
Textures
Clothes
Noises
Food
Lights
Other
Sensory Seeking
*
Self-injurious behavior
Self crashing or banging
Excessive screen time/watching repetitively
Mouthing non-food items
Other
Other Sensory Aversions
*
(Please describe)
Other Sensory Seeking
*
(Please describe)
Expressive Language
*
Non-verbal
Less than 10 words
25-50 words
Phrases
Full sentences
Social
*
Isolated
Interacts with prompting
Spontaneously interacts
Self-help
*
Eats with utensils
Dresses self
Accepts bath, hair/teeth brushing assistance
Play
*
Repetitive
Pretend
Please explain the repetitive behavior
*
Please explain the pretend behavior
*
Other Concerns
Services & Programs
PLEASE CHECK SERVICES OR PROGRAMS YOUR CHILD IS RECEIVING AND THEN WRITE NUMBER OF TIMES PER WEEK YOUR CHILD GOES TO THERAPY.
Please select a service or program
Speech
Occupational
Physical
ABA/DI
Speech Early Intervention
Less than 3 years of age; Times Per Week:
Speech Private Therapy
Less than 3 years of age; Times Per Week:
Speech School Therapy
More than 3 years of age; Times Per Week:
Speech Private Therapy
More than 3 years of age; Times Per Week:
Occupational Early Intervention
Less than 3 years of age; Times Per Week:
Occupational Private Therapy
Less than 3 years of age; Times Per Week:
Occupational School Therapy
More than 3 years of age; Times Per Week:
Occupational Private Therapy
More than 3 years of age; Times Per Week:
Physical Early Intervention
Less than 3 years of age; Times Per Week:
Physical Private Therapy
Less than 3 years of age; Times Per Week:
Physical School Therapy
More than 3 years of age; Times Per Week:
Physical Private Therapy
More than 3 years of age; Times Per Week:
ABA/DI Early Intervention
Less than 3 years of age; Times Per Week:
ABA/DI Private Therapy
Less than 3 years of age; Times Per Week:
ABA/DI School Therapy
More than 3 years of age; Times Per Week:
ABA/DI Private Therapy
More than 3 years of age; Times Per Week:
School Information
School Name
District
Please select
Pre-school
Kindergarten
Half Day
Full Day
IEP Provided
IEP Reviewed
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