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OPD : 02-Oct-2026 03:16PM Demographic Details Child's Name: Agastaya Shrivastav Age: 2 Year 6 Month 8 Days Gender: Male DOB: 2023-03-24 Mother’s age (years): 33 years Mother’s occupation: Teacher Father’s age (years): 36 years Father’s occupation: Banking Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Alkapuri Contact: 8964914560 Referred By: Doctor Informant: Parents, grandparents Presenting Concerns Chief concerns: Poor response to name call Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Spinni ng, climbing stairs up and down Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Emotional history: Excessive crying episodes Others Emotional History Details: Irrelevant laughing Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Details:: Doesnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH Gestational Age: Late PT Birth Weight: 1.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Kept in NICU for 1 day for observation Past history: Hospitalization: Yes Seizures: No Others: Admitted for AFI 2 months back Past/Current therapies: Nil Past/Current medications: Risnia- 0.25ml since 7 days 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: Sitting without support: Achieved Age of attainment: 10 months Standing without support: Achieved Age of attainment: 18 months Walking without support: Achieved Age of attainment: 24 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 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: 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: 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 Asking for food and toilet: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 1-2 minutes 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: Diet History: Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 11 Kg Height: 87 cm Head circumference: 47.5 cm 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: Improper Sucking: Improper Examination summary: Sits in w position. M chat -15 CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD Advice Intervention plan: IDP 2/week + PMT 1/week Medications: Syp Risnia (1mg/ml) 0.25 ml HAS Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-Oct-2026 03:16PM Demographic Details

Child's Name: Agastaya Shrivastav
Age: 2 Year 6 Month 8 Days
Gender: Male
DOB: 2023-03-24
Mother’s age (years): 33 years
Mother’s occupation: Teacher
Father’s age (years): 36 years
Father’s occupation: Banking
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Alkapuri
Contact: 8964914560
Referred By: Doctor
Informant: Parents, grandparents

Presenting Concerns

Chief concerns: Poor response to name call

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Spinni ng, climbing stairs up and down Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Emotional history:
Excessive crying episodes Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure

Details:: Doesnt cooperate for haircut

Birth & Perinatal History: Antenatal History

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

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH
Gestational Age: Late PT
Birth Weight: 1.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Kept in NICU for 1 day for observation

Past history:

Hospitalization: Yes Seizures: No Others: Admitted for AFI 2 months back

Past/Current therapies: Nil Past/Current medications: Risnia- 0.25ml since 7 days 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:
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Achieved

Age of attainment: 18 months
Walking without support: Achieved

Age of attainment: 24 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

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: 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: 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
Asking for food and toilet: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 1-2 minutes

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:

Diet History:

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg Height: 87 cm Head circumference: 47.5 cm

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: Improper
Sucking: Improper

Examination summary: Sits in w position. M chat -15 CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ? ASD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Medications: Syp Risnia (1mg/ml) 0.25 ml HAS
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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