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OPD : 26-Aug-2026 03:47PM Demographic Details Child's Name: Samarth Rai Age: 2 Year 1 Month 30 Days Gender: Male DOB: 2024-06-27 Mother’s age (years): 28 years Mother’s occupation: Banking Father’s age (years): 29 years Father’s occupation: Homemaker Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Shivpuri Contact: 9669835547 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Doesnt follow command Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Inattention Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive Visual: Seeks visuals Details:: Doesnt cooperate for haircut and nailcut Birth & Perinatal History: Antenatal History Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: Late PT Birth Weight: 1.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: At 1.5 month admitted for AGE Investigations done- Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 10 months Standing without support: Achieved Age of attainment: 14 months Walking without support: Achieved Age of attainment: 18 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: Not achieved 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: 10 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 10 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:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Details: 8/10 Sitting tolerance- (in 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 : 3. Onlooker 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): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2-2.5 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: M chat R score- 11 Impression: ? ASD Advice Intervention plan: Home Based Program Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 26-Aug-2026 03:47PM Demographic Details

Child's Name: Samarth Rai
Age: 2 Year 1 Month 30 Days
Gender: Male
DOB: 2024-06-27
Mother’s age (years): 28 years
Mother’s occupation: Banking
Father’s age (years): 29 years
Father’s occupation: Homemaker
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Shivpuri
Contact: 9669835547
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Doesnt follow command

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Inattention
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive
Visual: Seeks visuals

Details:: Doesnt cooperate for haircut and nailcut

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: Late PT
Birth Weight: 1.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: At 1.5 month admitted for AGE

Investigations done-

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Achieved

Age of attainment: 14 months
Walking without support: Achieved

Age of attainment: 18 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: Not achieved

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: 10 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 10 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:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Details: 8/10

Sitting tolerance- (in 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 : 3. Onlooker 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): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-2.5 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Examination summary: M chat R score- 11

Impression: ? ASD

Advice

Intervention plan: Home Based Program
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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