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OPD : 15-Sep-2026 01:30PM Demographic Details Child's Name: Tejas Dubey Age: 3 Year 1 Month 19 Days Gender: Male DOB: 2023-07-27 Contact: 8120000046 Current Improvements: Interaction, eye contact, command following improved Current concerns: Echolalia Interaction history: Eye contact: Suboptimal Interaction: Interaction improved with family members Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Spinning Reduced Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure 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: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5-7 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 Type of Play : 3. Onlooker 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): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: Zero 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: Improper Sucking: Improper Examination summary: Improvement in eye contact, attention span, sitting tolerance CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/15 days Evaluation: DQ, ISAA, DSM5 ASD Medications: Syp Autinorm 5 ml OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Sep-2026 01:30PM Demographic Details

Child's Name: Tejas Dubey
Age: 3 Year 1 Month 19 Days
Gender: Male
DOB: 2023-07-27
Contact: 8120000046
Current Improvements: Interaction, eye contact, command following improved
Current concerns: Echolalia

Interaction history:

Eye contact: Suboptimal
Interaction: Interaction improved with family members
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Spinning Reduced Patterned behavior or activities: Hyperactivity Inattention Temper tantrums Stubbornness
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

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: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5-7 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

Type of Play : 3. Onlooker 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): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: Zero

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: Improper
Sucking: Improper

Examination summary: Improvement in eye contact, attention span, sitting tolerance CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: IDP 2/week + PMT 1/15 days
Evaluation: DQ, ISAA, DSM5 ASD
Medications: Syp Autinorm 5 ml OD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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