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OPD : 10-Aug-2026 04:06PM Demographic Details Child's Name: Bhavya Pal Age: 3 Year 8 Month 15 Days Gender: Female DOB: 2022-11-26 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Government job Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: At maternal grandmother's place (Shivpuri) Contact: 7974301302 Referred By: Doctor Informant: Nani, mausa, mama Presenting Concerns Chief concerns: Doent eat Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Toe walking, Looking from lateral side of eye Patterned behavior or activities: Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hyposensitive Details:: Continuously listens to mobile songs Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Mode of Delivery: LSCS Indication for LSCS (if applicable): Malpresentation Gestational Age: FT Birth Weight: Not known 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: 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: 10 months Walking without support: Achieved Age of attainment: 11 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: 9 months Pincer grasp: Achieved Age of attainment: 12 months Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Not achieved Pointing: Achieved Age of attainment: ?12mon Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Emerging Pointing: Attempts 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 Asking for food and toilet: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Sits with mobile 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: Picky eater Food allergies: No Junk food intake: Daily Protein intake: Has not eaten chappati since 1 year Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hours Sleep disturbances: Yes Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Height: 96 cm Head circumference: 49.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Cafe au lait macule at4*3 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) 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. Aggression++. Ensure zero screen time then to review next month Advice Intervention plan: Home strategies Evaluation: ISAA, DSM5 ASD Medications: Syp sizodon (1mg/ml) 0.2 ml at evening 7 PM, Syp Multivitamin A to Z 5 ml BD. Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 10-Aug-2026 04:06PM Demographic Details

Child's Name: Bhavya Pal
Age: 3 Year 8 Month 15 Days
Gender: Female
DOB: 2022-11-26
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Government job
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: At maternal grandmother's place (Shivpuri)
Contact: 7974301302
Referred By: Doctor
Informant: Nani, mausa, mama

Presenting Concerns

Chief concerns: Doent eat

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Toe walking, Looking from lateral side of eye Patterned behavior or activities: Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Auditory: Hyposensitive

Details:: Continuously listens to mobile songs

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Mode of Delivery: LSCS
Indication for LSCS (if applicable): Malpresentation
Gestational Age: FT
Birth Weight: Not known
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: 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: 10 months
Walking without support: Achieved

Age of attainment: 11 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: 9 months

Pincer grasp: Achieved

Age of attainment: 12 months

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Not achieved
Pointing: Achieved

Age of attainment: ?12mon
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Emerging
Pointing: Attempts

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
Asking for food and toilet: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Sits with mobile

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: Picky eater
Food allergies: No
Junk food intake: Daily
Protein intake: Has not eaten chappati since 1 year

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hours
Sleep disturbances: Yes

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Height: 96 cm Head circumference: 49.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Cafe au lait macule at4*3 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

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. Aggression++. Ensure zero screen time then to review next month

Advice

Intervention plan: Home strategies
Evaluation: ISAA, DSM5 ASD
Medications: Syp sizodon (1mg/ml) 0.2 ml at evening 7 PM, Syp Multivitamin A to Z 5 ml BD.
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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