Autism Spectrum Disorder Assessment

To: 
Patient Information:
- Age at assessment: 
- Date of Assessment: 2026-01-14
- Source of Information: Parent report

Reason for Referral:
- Assessment for Avoidant/restrictive food intake disorder (F50.82) and Allergic rhinitis, unspecified (J30.9)
PARENTAL CONCERNS:
- Initial Concerns: Selective eating with preference for fruit and sweets, avoidance of rice, meats, and most vegetables; nasal symptoms and decreased appetite.
- Date of Initial Concern: 
- Actions Taken: Use of prescribed nasal spray; increased efforts to provide a more varied and balanced diet.
- School Information (if applicable):

DEVELOPMENTAL HISTORY:

LANGUAGE:

SOCIAL/EMOTIONAL:

RESTRICTED AND REPETITIVE BEHAVIORS (RRBs):

ACTIVITIES OF DAILY LIVING (ADL):

GROSS MOTOR (GM):

FINE MOTOR (FM):

COGNITIVE:

CHILDCARE/SCHOOL HISTORY:

FUNDING:

EQUIPMENT:

COMMUNITY ACTIVITIES:

PRE/POST-NATAL HISTORY & INFANCY:

PAST MEDICAL HISTORY:
- Medications: Nasal spray for nasal symptoms.
- Allergies: 
- Immunizations: 
- Eating/Diet: Selective eating; prefers fruit and sweets, avoids rice, meats, and most vegetables. Family is making efforts to offer a more balanced and varied diet. Weight gain of 1.5 kg over one month.

FAMILY AND SOCIAL HISTORY:

ASSESSMENT SUMMARY:
The patient presents with avoidant/restrictive food intake disorder (F50.82) and allergic rhinitis, unspecified (J30.9). Nasal symptoms have improved with nasal spray, with only occasional nighttime congestion. Selective eating persists, but there has been a healthy weight gain of 1.5 kg over one month. Family is encouraged to continue offering nutritious and varied foods without forcing intake and to limit sugar, especially sweets. Plan includes continued use of nasal spray as needed and follow-up in July or August to reassess growth and nutritional status.

MANAGEMENT PLAN AND RECOMMENDATION:
1. Support Services:
   - Continue current dietary approach, offering nutritious and varied foods without forcing intake.
   - Limit sugar intake, especially sweets.
   - Continue nasal spray as needed for nighttime congestion.
   - Schedule follow-up in July or August to reassess growth and nutritional status.
   - Clinic coordinator to contact family to arrange next appointment.

Thank you for involving me in this patient's care.

Sincerely,
Dr. Jamie Lin
Pediatrician