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OPD : 03-Jun-2026 09:30AM Demographic Details Child's Name: Avnish yadav Age: 3 Year 3 Month 22 Days Gender: Male DOB: 2023-02-12 Contact: 6260518537 Interaction history: Eye contact: Suboptimal Interaction: Improved with known people Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): stimming Patterned behavior or activities: Inattention Sensory Concerns: Details:: Movement seeking reduced 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: Consistent Drag for needs: Consistent Joint attention: Inconsistent Pointing: Cued pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 5-10 minutes For tasks: 15 minutes ADL Skills (Age-appropriate)- Eating: 4. Needs minimal 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 : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: No Sleep History Total sleep duration (night): 10 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 (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + LDP 1/week + PMT 1/15 days Medications: Syp Risdone (1mg/ml) 0.3 ml at evening 7:30 PM. Syp Autinorm 2.5 ml BD. Lactobrain sachet 1 OD for 3 months Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Jun-2026 09:30AM Demographic Details

Child's Name: Avnish yadav
Age: 3 Year 3 Month 22 Days
Gender: Male
DOB: 2023-02-12
Contact: 6260518537

Interaction history:

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

Behavioral history:

Repetitive behaviors (RRBs): stimming Patterned behavior or activities: Inattention
Sensory Concerns:

Details:: Movement seeking reduced

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: Consistent
Drag for needs: Consistent
Joint attention: Inconsistent
Pointing: Cued pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 5-10 minutes
For tasks: 15 minutes

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal 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 : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: No

Sleep History

Total sleep duration (night): 10 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 (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Advice

Intervention plan: IDP 2/week + LDP 1/week + PMT 1/15 days
Medications: Syp Risdone (1mg/ml) 0.3 ml at evening 7:30 PM. Syp Autinorm 2.5 ml BD. Lactobrain sachet 1 OD for 3 months
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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