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OPD : 09-Sep-2026 12:28PM Demographic Details Child's Name: Dherya Bhilwar Age: 7 Year 2 Month 28 Days Gender: Male DOB: 2019-04-24 Contact: 9827285970 Current Improvements: Interaction improved Current concerns: Hyperactivity, inattention Interaction history: Eye contact: Fleeting Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Stubbornness 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: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Additional information: Discontinued Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 2/week + PMT 1/week Evaluation: ISAA, DSM5 ASD Medications: Syp Autinorm 5 ml BD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 09-Sep-2026 12:28PM Demographic Details

Child's Name: Dherya Bhilwar
Age: 7 Year 2 Month 28 Days
Gender: Male
DOB: 2019-04-24
Contact: 9827285970
Current Improvements: Interaction improved
Current concerns: Hyperactivity, inattention

Interaction history:

Eye contact: Fleeting
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Stubbornness

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: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No
Additional information: Discontinued

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: ?ASD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Evaluation: ISAA, DSM5 ASD
Medications: Syp Autinorm 5 ml BD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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