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OPD : 10-Oct-2026 12:25PM Demographic Details Child's Name: Kunj Agrawal Age: 4 Year Gender: Male DOB: 2022-09-22 Mother’s age (years): 36 years Mother’s occupation: Homemaker Father’s age (years): 40 years Father’s occupation: Business Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Konch Contact: 6394245393 Referred By: Healthcare worker Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hand flapping, spinning, stimming, jumping, toe walking Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress Gestational Age: FT Birth Weight: Not known Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 7 days. Respiratory distress and NNHB Past history: Hospitalization: No Seizures: No 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: 14 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: Achieved Age of attainment: Inconsistent Pointing: Achieved Age of attainment: Inconsistent Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Details:: Started using few kinship words inconsistently Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Emerging Pointing: Attempts Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Not achieved Comes when called: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) For interaction: 2-3 minutes For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Cooperates for brushing Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: SN gupta Hours spent in school: 1 Location: Konch, jaloun Additional information: discontinued Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Chips, Toffee alternate days Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: > 2 hours 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: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: Home Based Program Evaluation: DQ, ISAA, DSM5 ASD Investigations: CBC, vitamin D, Vitamin B12, thyroid profile, Homocystein , S. Lead Medications: Syp Sizodon 0.3 ml for 7 days then increase to 0.4 ml for 7 days then 0.5 ml. Rest same Follow up plan: Next month

OPD : 10-Oct-2026 12:25PM Demographic Details

Child's Name: Kunj Agrawal
Age: 4 Year
Gender: Male
DOB: 2022-09-22
Mother’s age (years): 36 years
Mother’s occupation: Homemaker
Father’s age (years): 40 years
Father’s occupation: Business
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Konch
Contact: 6394245393
Referred By: Healthcare worker
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, spinning, stimming, jumping, toe walking Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

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

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 7 days. Respiratory distress and NNHB

Past history:

Hospitalization: No Seizures: No

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: 14 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: Achieved

Age of attainment: Inconsistent
Pointing: Achieved

Age of attainment: Inconsistent
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Details:: Started using few kinship words inconsistently

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Emerging
Pointing: Attempts
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Not achieved
Comes when called: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

For interaction: 2-3 minutes
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Details:: Cooperates for brushing

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: SN gupta
Hours spent in school: 1
Location: Konch, jaloun
Additional information: discontinued

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Chips, Toffee alternate days

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: > 2 hours

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: Proper
Sucking: Proper

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

Impression: ASD

Advice

Intervention plan: Home Based Program
Evaluation: DQ, ISAA, DSM5 ASD
Investigations: CBC, vitamin D, Vitamin B12, thyroid profile, Homocystein , S. Lead
Medications: Syp Sizodon 0.3 ml for 7 days then increase to 0.4 ml for 7 days then 0.5 ml. Rest same
Follow up plan: Next month

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