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OPD : 29-Aug-2026 02:17PM Demographic Details Child's Name: Rudra Singh Age: 5 Year 10 Month 20 Days Gender: Male DOB: 2020-10-09 Mother’s age (years): 42 years Mother’s occupation: Homemaker Father’s age (years): 42 years Father’s occupation: Business Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Dabra Contact: 6264817808 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Behavioral concerns, communication Concerns noticed by school (if any): Behavioral concerns Interaction history: Eye contact: Suboptimal Interaction: Approaches people Behavioral history: Repetitive behaviors (RRBs): fisting Patterned behavior or activities: Hyperactivity Inattention Impulsivity Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Maternal age at conception (years):: 37 Type of conception: Natural High-risk factors in pregnancy: PIH Others:: PCOS in mother. Took infertility treatment but conceived naturally. Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH, fetal distress Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 10 days for respiratory distress ? CHD Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: normal Vision assessment: Done Details: normal 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: 7 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 14 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: 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: Achieved Age of attainment: Drinking from cup: Not achieved Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: 5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Achieved Age of attainment: 5 years Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 5-10 minutes For tasks: 10-15 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Brushing- attempts Type of Play : 4. Parallel Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Jack and Jill Grade: LKG Hours spent in school: 3 hours Location: Dabra Additional information: Behavioral concerns in school. Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hour Sleep disturbances: Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 37.1 Kg Height: 125 cm Head circumference: 53 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper 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, s. Homocysteine, Vitamin D, Vitamin B12 General recommendation- Zero Screen Time Physical interactive play

OPD : 29-Aug-2026 02:17PM Demographic Details

Child's Name: Rudra Singh
Age: 5 Year 10 Month 20 Days
Gender: Male
DOB: 2020-10-09
Mother’s age (years): 42 years
Mother’s occupation: Homemaker
Father’s age (years): 42 years
Father’s occupation: Business
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Dabra
Contact: 6264817808
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Behavioral concerns, communication
Concerns noticed by school (if any): Behavioral concerns

Interaction history:

Eye contact: Suboptimal
Interaction: Approaches people

Behavioral history:

Repetitive behaviors (RRBs): fisting Patterned behavior or activities: Hyperactivity Inattention Impulsivity Stubbornness Aggression Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

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

Birth & Perinatal History: Antenatal History

Consanguinity: No
Maternal age at conception (years):: 37
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
Others:: PCOS in mother. Took infertility treatment but conceived naturally.

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH, fetal distress
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 10 days for respiratory distress ? CHD

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: normal Vision assessment: Done Details: normal

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: 7 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 14 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: 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: Achieved

Age of attainment:

Drinking from cup: Not achieved

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: 5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Achieved

Age of attainment: 5 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 5-10 minutes
For tasks: 10-15 minutes

ADL Skills (Age-appropriate)-

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

Details:: Brushing- attempts

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Jack and Jill
Grade: LKG
Hours spent in school: 3 hours
Location: Dabra
Additional information: Behavioral concerns in school.

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hour
Sleep disturbances:

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

Weight: 37.1 Kg Height: 125 cm Head circumference: 53 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

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, s. Homocysteine, Vitamin D, Vitamin B12
General recommendation-
1. Zero Screen Time
2. Physical interactive play

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