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Patient Details


OPD : 08-Aug-2026 01:23PM Demographic Details Child's Name: Tejas Dubey Age: 2 Year 11 Month 13 Days Gender: Male DOB: 2023-07-27 Contact: 8120000046 Current Improvements: Eye contact, interaction improved Current concerns: Stubborness Interaction history: Eye contact: Fleeting Interaction: Improved with parents Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Reduced Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Patterned speech: Present Social Response to Name Call Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5-7 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 2/week + PMT 1/week Evaluation: DQ, ISAA, DSM5 ASD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Aug-2026 01:23PM Demographic Details

Child's Name: Tejas Dubey
Age: 2 Year 11 Month 13 Days
Gender: Male
DOB: 2023-07-27
Contact: 8120000046
Current Improvements: Eye contact, interaction improved
Current concerns: Stubborness

Interaction history:

Eye contact: Fleeting
Interaction: Improved with parents
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Reduced Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5-7 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ?ASD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Evaluation: DQ, ISAA, DSM5 ASD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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