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Patient Details


OPD : 03-Aug-2026 10:35AM Demographic Details Child's Name: Vivan Baghel Age: 2 Year 7 Month 8 Days Gender: Male DOB: 2023-09-21 Contact: 9617090649 Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Temper tantrums Sensory Concerns: Auditory: Hypersensitive 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: Emerging Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 5-10 minutes For tasks: 10-15 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-1.5 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 15.35 Kg Head circumference: 49 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Advice Intervention plan: IDP 2/week + PMT 1/15 days Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Aug-2026 10:35AM Demographic Details

Child's Name: Vivan Baghel
Age: 2 Year 7 Month 8 Days
Gender: Male
DOB: 2023-09-21
Contact: 9617090649

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

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

Auditory: Hypersensitive

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: Emerging
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 5-10 minutes
For tasks: 10-15 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-1.5 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 15.35 Kg Head circumference: 49 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Advice

Intervention plan: IDP 2/week + PMT 1/15 days
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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