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OPD : 15-Jun-2026 02:26PM Demographic Details Child's Name: Dharmik Tomar Age: 2 Year 3 Month 27 Days Gender: Male DOB: 2024-02-19 Mother’s age (years): 20 years Mother’s occupation: Homemaker Father’s age (years): 25 years Father’s occupation: Indian railways canteen work Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: DD Nagar Contact: 9098449833 Referred By: Doctor Informant: Mother Presenting Concerns Duration of symptoms: Noticed since 1 year Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hand flapping, toe walking, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Details:: Doesnt cooperate for haircut and nailcut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Pre-eclampsia Hypothyroidism Others:: Gestational hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Pre ecclampsia Gestational Age: FT Birth Weight: Not known Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: Frequent episodes of AGE. Admitted once. 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: 3 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: 12 months Running: Achieved Age of attainment: Climbing upstairs: Not achieved Climbing downstairs: Not achieved 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 Scribbling: Not achieved Drinking from cup: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 18 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 18 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Copying parents in tasks: 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: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting 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: Mixed Food allergies: No Junk food intake: 1,2/week Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 4 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 13 Kg Height: 84 cm Head circumference: 47 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Improper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: M chat autism speaks- 15 (High risk) CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD. M chat R score- 15 Advice Intervention plan: IDP 1/week + PMT 1/week Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Jun-2026 02:26PM Demographic Details

Child's Name: Dharmik Tomar
Age: 2 Year 3 Month 27 Days
Gender: Male
DOB: 2024-02-19
Mother’s age (years): 20 years
Mother’s occupation: Homemaker
Father’s age (years): 25 years
Father’s occupation: Indian railways canteen work
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: DD Nagar
Contact: 9098449833
Referred By: Doctor
Informant: Mother

Presenting Concerns

Duration of symptoms: Noticed since 1 year

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

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

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

Details:: Doesnt cooperate for haircut and nailcut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Pre-eclampsia
2. Hypothyroidism
Others:: Gestational hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Pre ecclampsia
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: Frequent episodes of AGE. Admitted once.

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: 3 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: 12 months
Running: Achieved

Age of attainment:
Climbing upstairs: Not achieved
Climbing downstairs: Not achieved

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

Scribbling: Not achieved

Drinking from cup: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 18 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 18 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved
Copying parents in tasks: 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: Better for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
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: Mixed
Food allergies: No
Junk food intake: 1,2/week

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 4 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 13 Kg Height: 84 cm Head circumference: 47 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Improper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

Examination summary: M chat autism speaks- 15 (High risk) CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ? ASD. M chat R score- 15

Advice

Intervention plan: IDP 1/week + PMT 1/week
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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