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OPD : 31-Aug-2026 01:13PM Demographic Details Child's Name: Adhvik Age: 3 Year 1 Month 2 Days Gender: Male DOB: 2023-07-29 Mother’s age (years): 34 years Mother’s occupation: Interior designer Father’s age (years): 34 years Father’s occupation: Research work Type of family: Nuclear Address: Gurgaon Contact: 7067267393 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): spinning Patterned behavior or activities: Inattention Impulsivity Insisting on sameness Temper tantrums Stubbornness Aggression Sensory Concerns: Proprioception: Seeks pressure Details:: Doesnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o Diabetes mellitus in mother. Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: OAE- pass 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: 6 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 12 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 Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Inconsistent Pointing: Achieved Age of attainment: Understanding gestures: Achieved Age of attainment: Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging 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 Comes when called: Not achieved Response to Name Call Details: 0/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt indicate for urine and stool. Toilet training going on Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Play school Grade: Play group Hours spent in school: 3 hours Location: Gurgaon Additional information: Doesnt mingle with kids 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: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 13 Kg Height: 90 cm Head circumference: 50 cm c. General Examination Neurocutaneous markers: Cafe au lait macules+ 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: ISAA, DSM5 ASD Investigations: CBC, Calcium, Vitamin D, Vitamin B12, Thyroid profile, HbA1c. MRI Brain (Later) General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 31-Aug-2026 01:13PM Demographic Details

Child's Name: Adhvik
Age: 3 Year 1 Month 2 Days
Gender: Male
DOB: 2023-07-29
Mother’s age (years): 34 years
Mother’s occupation: Interior designer
Father’s age (years): 34 years
Father’s occupation: Research work
Type of family: Nuclear
Address: Gurgaon
Contact: 7067267393
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): spinning Patterned behavior or activities: Inattention Impulsivity Insisting on sameness Temper tantrums Stubbornness Aggression
Sensory Concerns:

Proprioception: Seeks pressure

Details:: Doesnt cooperate for haircut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o Diabetes mellitus in mother.

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: OAE- pass 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: 6 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 12 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

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Inconsistent
Pointing: Achieved

Age of attainment:
Understanding gestures: Achieved

Age of attainment:
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
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
Comes when called: Not achieved

Response to Name Call

Details: 0/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Doesnt indicate for urine and stool. Toilet training going on

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Play school
Grade: Play group
Hours spent in school: 3 hours
Location: Gurgaon
Additional information: Doesnt mingle with kids

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: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 13 Kg Height: 90 cm Head circumference: 50 cm

c. General Examination

Neurocutaneous markers: Cafe au lait macules+

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: ISAA, DSM5 ASD
Investigations: CBC, Calcium, Vitamin D, Vitamin B12, Thyroid profile, HbA1c. MRI Brain (Later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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