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OPD : 04-Sep-2026 11:03AM Demographic Details Child's Name: Kanha Sharma Age: 3 Year Gender: Male DOB: 2023-08-06 Mother’s age (years): 35 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Private job Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Details of siblings (Age and sex): 10 year old female Address: Jaipur Contact: 8000028129 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, behavioral concerns Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): running to and fro, head nodding Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD 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 Past/Current therapies: nil Past/Current medications: nil Investigations done- Hearing assessment: Done Details: OAE- B/l Pass Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 16 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 Scribbling: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: 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: 18 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 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 Comes when called: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: 2 minutes For tasks: 3-5 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt cooperate for Haircut Type of Play : 2. Isolated 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): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 3 hours Daily Screen Time Duration: < 2 hours 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 Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD. M chat- 11 Advice Intervention plan: HBP Evaluation: ISAA, DSM5 ASD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 04-Sep-2026 11:03AM Demographic Details

Child's Name: Kanha Sharma
Age: 3 Year
Gender: Male
DOB: 2023-08-06
Mother’s age (years): 35 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Private job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Details of siblings (Age and sex): 10 year old female
Address: Jaipur
Contact: 8000028129
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, behavioral concerns

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): running to and fro, head nodding Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
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

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

Hearing assessment: Done Details: OAE- B/l Pass Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 16 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

Scribbling: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: 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: 18 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 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
Comes when called: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: 2 minutes
For tasks: 3-5 minutes

ADL Skills (Age-appropriate)-

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

Details:: Doesnt cooperate for Haircut

Type of Play : 2. Isolated 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): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3 hours

Daily Screen Time

Duration: < 2 hours
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

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

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

Impression: ? ASD. M chat- 11

Advice

Intervention plan: HBP
Evaluation: ISAA, DSM5 ASD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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