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OPD : 07-Oct-2026 11:04AM Demographic Details Child's Name: shiva Sharma Age: 2 Year 7 Month 6 Days Gender: Male DOB: 2024-03-01 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: works in Private college Type of family: Joint Number of family members: 9 Number of siblings: 0 Address: Kailaras Contact: 8223808877 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, stay isolated Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Spinning, hand flapping, running to and fro, /toe walking, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing, crying Sensory Concerns: Tactile: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor, oligo Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: MAS, RD, at 5 hours age- vomited, aspirated- shifted to NICU. On MV- 3 days. Discharged 5 days. Past history: Hospitalization: Yes Seizures: No Others: Admitted twice for AGE 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: 6 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 12 months 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: 8 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 8 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: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: 1-2/10 Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Doesnt cooperate for brushing, haircut or combing Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Biscuit Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 13 Kg Head circumference: 50 cm c. General Examination Neurocutaneous markers: 1 cafe au lait macule over back 1*0.5 cm 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: M chat r score- 16 (High risk). ASD Advice Intervention plan: Home Based Program Evaluation: DQ, ISAA, DSM5 ASD (Later) Investigations: BERA, Fragile X TP PCR (later) Medications: Syp Sizodon91mg/ml) 0.1 ml at evening 8 PM. Rest ad adviced by pediatrician Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 07-Oct-2026 11:04AM Demographic Details

Child's Name: shiva Sharma
Age: 2 Year 7 Month 6 Days
Gender: Male
DOB: 2024-03-01
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: works in Private college
Type of family: Joint
Number of family members: 9
Number of siblings: 0
Address: Kailaras
Contact: 8223808877
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, stay isolated

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Spinning, hand flapping, running to and fro, /toe walking, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing, crying
Sensory Concerns:

Tactile: Hyposensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

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

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor, oligo
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: MAS, RD, at 5 hours age- vomited, aspirated- shifted to NICU. On MV- 3 days. Discharged 5 days.

Past history:

Hospitalization: Yes Seizures: No Others: Admitted twice for AGE

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: 6 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 12 months

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: 8 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 8 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: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: 1-2/10

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Details:: Doesnt cooperate for brushing, haircut or combing

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Biscuit

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 13 Kg Head circumference: 50 cm

c. General Examination

Neurocutaneous markers: 1 cafe au lait macule over back 1*0.5 cm

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: M chat r score- 16 (High risk). ASD

Advice

Intervention plan: Home Based Program
Evaluation: DQ, ISAA, DSM5 ASD (Later)
Investigations: BERA, Fragile X TP PCR (later)
Medications: Syp Sizodon91mg/ml) 0.1 ml at evening 8 PM. Rest ad adviced by pediatrician
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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