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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

NAME: Devyani singh D.O.B: 23-07-2016 Parent’s Name:

Rajshri Bundela

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 )

No complications during pregnancy .Birth weight was 3 kg

at 8 th month ultrasound it was low as doctor told me.

2. Were there any Complications during delivery, if yes , please give details.

At the time of delivery it was supposed to be normal I started to get

labour pain from 4 am morning and it was not sharp pain we reached hosital at 8 pm and then
nurses provide me injections to increase labour pain to sharper level and I started to get very sharp
pain I was unable to bear the pain and I myself opted for cesearean delivery by c section .Devyani
cried after birth .She was so fragile looking .

3. Did the child cry immediately after birth?

yes
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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 .

Neck holding Normal yes Slightly Delayed Delayed

Teething Normal Slightly Delayed yes Delayed

Crawling Normal Slightly Delayed Delayed yes

Walking Normal yes Slightly Delayed Delayed

Speech delayed Normal Slightly Delayed Delayed

5. Present Medicines being given to the child

1 baryta carbonica 30 ml 2 drops morning

2. Borax 30 ml 2 drops afternoon

3. Chamomilla 30 ml 2 drops evening

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6. History of Medicines being given the child

Till 1 year allopathic medicines

From August 2018 to April 2019 allopathic medicines were given .then after we
switched to homeopathic medicines.

TESTS:

Conducted Normal Abnormality detected

BERA(Hearing test) Yes/ No Yes/ No No

EEG: Yes/ No Yes/ No yes

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MRI: Yes/ No Yes/ No yes

CT: Yes/ No Yes/ No yes

THYROID: Yes/ No Yes/ No yes

Genetic test: Yes/ No Yes/ No no

1.Health Physical Behavior

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 Health Physical behavior Value
0 1 2 3 The child does bedwetting 1
0 1 2 3 The child wets pants and diapers 1

0 1 2 3 The child soils pants and diapers 1

0 1 2 3 The child has recurrent diarrhea 2
0 1 2 3 The child has regular constipation 3
0 1 2 3 The child has sleep problems 3
0 1 2 3 The child eats too much or too little 3
0 1 2 3 The child has extremely limited diet 3
0 1 2 3 The child is hyperactive 2
0 1 2 3 The child is sound sensitive 3
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0 1 2 3 The child is always fearful and anxious 3

0 1 2 3 The child is lethargic 2
0 1 2 3 The child is always unhappy and crying 2
0 1 2 3 The child is destructive 3
0 1 2 3 The child hits or injures self 0
0 1 2 3 The child hits or injures others 2
0 1 2 3 The child has had seizures 0
0 1 2 3 The child has obsessive speech 0
0 1 2 3 The child has rigid routines 3
0 1 2 3 The child screams or shouts too often 3
0 1 2 3 The child demands sameness 3
0 1 2 3 The child is often agitated 3
0 1 2 3 The child has reduced sensitivity to pain 1
0 1 2 3 The child is hooked or fixated on certain objects 3
0 1 2 3 The child has repetitive movements like rocking 0
and stemming
before carrying on to the next section Total all the
points

2.SENSORY AND COGNITIVE AWARENESS

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 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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0 1 2 3 The child is not aware of environment 3

0 1 2 3 The child is not aware of danger 3
0 1 2 3 The child does not shows imagination 3
0 1 2 3 The child does not initiates activities 3
0 1 2 3 The child does not dresses self 3
0 1 2 3 The child is not curious and interested 3
0 1 2 3 The child is not venturesome and does not explore 0
0 1 2 3 The child is not tuned in and not spacey 3
0 1 2 3 The child does not look where all others are 3
looking
before carrying on to the next section Total all the
points

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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0 1 2 3 The child shows no affection 1

0 1 2 3 The child fails to greet parents when they come 0
home
0 1 2 3 The child avoids contact with others 3
0 1 2 3 The child does not imitate 3
0 1 2 3 The child dislikes being held or cuddled 1
0 1 2 3 The child does not share or show 3
0 1 2 3 The child does not wave bye-bye 3
0 1 2 3 The child is disagreeable and not compliant 3
0 1 2 3 The child shows temper tantrums 3
0 1 2 3 The child lacks friends and companions 3
0 1 2 3 The child rarely smiles 2
0 1 2 3 The child is insensitive to others feelings 3
0 1 2 3 The child is indifferent to being liked 1
0 1 2 3 The child is indifferent if parents leave 0
before carrying on to the next section Total all the
points

4.Speech and language

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 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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0 1 2 3 The child does not know more than 10 words 3

0 1 2 3 The child cannot use sentences with 4 or more 3
words
0 1 2 3 The child cannot explain what he or she wants 3
0 1 2 3 The child does not ask meaningful questions 3
0 1 2 3 The child Speech tends to be 3
meaningless/irrelevant
0 1 2 3 The child is not able to use successive sentences 3
0 1 2 3 The child cannot carry a good conversation 3
0 1 2 3 The child does not have the normal ability to 3
communicate for his/her age
Total all the points

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

 It is the responsibility of the patient to check if the homeopathic

medicines are allowed by the custom department in their country.
 Medicines will be sent by Indian postal services, to the places where
sending the medicines by courier is not possible.
 The patient/parent can enquire about the prescribed medications, but
no explanations will be provided for the prescriptions.
 In case the patient misses 2 appointments, then the 3rd appointment
will be scheduled after 10 days.
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 It is the duty of the patient/parent to ask for the follow-up

appointment, as it is not possible for us to accurately calculate when
the patient has started or completed the given course of medicines.
 We will appreciate if the logged in patients can preferably e-mail us to
ask for an appointment or in case of any need/help, as
communicating via e-mails, allows us to maintain the treatment
records in a much systematic manner.
 The patient/parent has to call us at the time of the appointment that
has been scheduled for them.
 If the patient has not received the medicines on time then we shall be
resending the medicines after verifying the cause of delay.
 Indian nationals, who are residing outside India or are tax payee in
any other country, will be treated as an International patient and
hence the treatment charges for the International patients will be
applicable. In case of any doubt, the patient /parent will be requested
to send the proof for the same.
 The refund will only be approved if any proof of payment is attached
along with the request for refund.
 Certain limitations are involved in an online treatment hence we are
also dependent on the information provided by the patient/parent.
Although we try to bridge all the limitations by intensive case
analysis. Therefore, we expect the patients to provide us with the
detailed information regarding the disease, history of disease, the
medicines currently being used.
 The biggest limitation in online treatment is that in case of any
emergency, we will not be able to examine the patient. Hence, we
expect the patient to take a proactive role in treating the acute
emergency condition by contacting the local hospital. In such a
scenario our clinic (attending physician) will not be responsible for
eventuality or consequences resulting from any such eventuality.
 Although Homeopathic medicines are highly diluted and do not cause
any side effects, our clinic will not be responsible for any idiosyncratic
reaction to the prescribed Homeopathic medication.
 The refund policy and the terms of use can change at any given time
without any prior notice.
 Walk-in appointment will be subjected to availability of appointment
with Dr. Vikas.
 Duration of plan for online patients will be calculated as mentioned in
the example below:-
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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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