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OPD : 15-Sep-2026 02:50PM Demographic Details Child's Name: Harshvardhan Singh Age: 2 Year 4 Month 30 Days Gender: Male DOB: 2024-04-16 Mother’s age (years): 35 years Mother’s occupation: Govt job Father’s age (years): 41 years Father’s occupation: LIC agent Type of family: Nuclear Number of siblings: 1 Details of siblings (Age and sex): 11 year old male Address: Sabalgarh Contact: 9584713141 Referred By: Doctor Informant: Parents Investigations done: BERA- normal Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.750 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: Syp Mentat, Syp Carnosine. Discontinued. Investigations done- Hearing assessment: Done Details: BERA- normal 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: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Not achieved Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Not achieved Babbling: Achieved Age of attainment: 9 months Meaningful words: Not achieved 2 word Phrases: 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: 4 months Stranger anxiety: Achieved Age of attainment: 12 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: 1/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent 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: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: > 5 hours Examination a. Vitals: b. Anthropometry: Weight: 12.5 Kg Height: 90 cm Head circumference: 48 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait patch 2.5*12 cm over Right forearm ventral aspect d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Improper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD. M chat- 16 (High risk) Advice Intervention plan: HBP or Hybrid Evaluation: ISAA, DSM5 ASD Investigations: MRI Brain (Later) Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Sep-2026 02:50PM Demographic Details

Child's Name: Harshvardhan Singh
Age: 2 Year 4 Month 30 Days
Gender: Male
DOB: 2024-04-16
Mother’s age (years): 35 years
Mother’s occupation: Govt job
Father’s age (years): 41 years
Father’s occupation: LIC agent
Type of family: Nuclear
Number of siblings: 1
Details of siblings (Age and sex): 11 year old male
Address: Sabalgarh
Contact: 9584713141
Referred By: Doctor
Informant: Parents
Investigations done: BERA- normal

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.750 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: Syp Mentat, Syp Carnosine. Discontinued. Investigations done-

Hearing assessment: Done Details: BERA- normal 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: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Not achieved

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Not achieved

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Not achieved

2 word Phrases: 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: 4 months
Stranger anxiety: Achieved

Age of attainment: 12 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: 1/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
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: Mixed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: > 5 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.5 Kg Height: 90 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait patch 2.5*12 cm over Right forearm ventral aspect

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

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

Impression: ? ASD. M chat- 16 (High risk)

Advice

Intervention plan: HBP or Hybrid
Evaluation: ISAA, DSM5 ASD
Investigations: 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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