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OPD : 02-Sep-2026 03:13PM Demographic Details Child's Name: Kavya Shivhare Age: 2 Year 11 Month 21 Days Gender: Female DOB: 2023-09-12 Mother’s age (years): 34 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Business Type of family: Joint Number of family members: 12 Number of siblings: 1 Details of siblings (Age and sex): 1.5 year male Address: Shivpuri Contact: 9584593350 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Irrelevant speech, doesnt command follow Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): hand flapping, spinning Hyperactivity Inattention Object obsession Temper tantrums Stubbornness Aggression Encopresis Others Emotional History Details: Irrelevant laughing Sensory Concerns: Tactile: Hypersensitive Details:: Deosnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Polyhydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): CPD, Polyhydramnios Gestational Age: Late PT Birth Weight: 3.5 Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 5 days ? Perinatal asphyxia Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 7 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 14 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: 5 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting 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 Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Impression: ASD. ? Advice Intervention plan: IDP 1/week + PMT 1/week Investigations: BERA. CBC, S calcium, Vitamin D, Vitamin B12, Thyroid profile. MRI Brain (Later) Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-Sep-2026 03:13PM Demographic Details

Child's Name: Kavya Shivhare
Age: 2 Year 11 Month 21 Days
Gender: Female
DOB: 2023-09-12
Mother’s age (years): 34 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 12
Number of siblings: 1
Details of siblings (Age and sex): 1.5 year male
Address: Shivpuri
Contact: 9584593350
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Irrelevant speech, doesnt command follow

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): hand flapping, spinning Hyperactivity Inattention Object obsession Temper tantrums Stubbornness Aggression Encopresis Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Tactile: Hypersensitive

Details:: Deosnt cooperate for haircut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Polyhydramnios

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): CPD, Polyhydramnios
Gestational Age: Late PT
Birth Weight: 3.5 Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 5 days ? Perinatal asphyxia

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 7 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 14 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: 5 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
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

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Impression: ASD. ?

Advice

Intervention plan: IDP 1/week + PMT 1/week
Investigations: BERA. CBC, S calcium, Vitamin D, Vitamin B12, Thyroid profile. MRI Brain (Later)
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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