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OPD : 18-Aug-2026 11:20AM Demographic Details Child's Name: Rudransh Nagar Age: 2 Year 11 Month 0 Days Gender: Male DOB: 2023-09-18 Contact: 7999144258 Interaction history: Eye contact: Suboptimal Interaction: Improved with known people Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Jumping Patterned behavior or activities: Temper tantrums Sensory Concerns: Auditory: Fear of loud sounds Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Attempts Understanding gestures: Absent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: 3-5 minutes For tasks: 5-7 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Type of Play : 4. Parallel Outdoor play duration: Inconsistent 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): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Head circumference: 50 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 1/week + LDP 1/week + PMT1/15 days Evaluation: DQ, ISAA, DSM 5 ASD (Next month) Medications: Continue syp MV and calcium Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-Aug-2026 11:20AM Demographic Details

Child's Name: Rudransh Nagar
Age: 2 Year 11 Month 0 Days
Gender: Male
DOB: 2023-09-18
Contact: 7999144258

Interaction history:

Eye contact: Suboptimal
Interaction: Improved with known people
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Jumping Patterned behavior or activities: Temper tantrums
Sensory Concerns:

Auditory: Fear of loud sounds

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Attempts
Understanding gestures: Absent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: 3-5 minutes
For tasks: 5-7 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Type of Play : 4. Parallel Outdoor play duration: Inconsistent 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): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 50 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Advice

Intervention plan: IDP 1/week + LDP 1/week + PMT1/15 days
Evaluation: DQ, ISAA, DSM 5 ASD (Next month)
Medications: Continue syp MV and calcium
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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