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OPD : 17-Apr-2026 03:02PM Demographic Details Child's Name: Prabal Tomar Age: 4 Year Gender: Male DOB: 2022-03-19 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 29 years Father’s occupation: Army (Poonch) Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 1 month -/*9/ Address: D D Nagar Contact: 8450888959 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Hyperactivity, Poor human interaction Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Dengue in 2nd trimester in mother- admitted for 4 days Natal and Postnatal History: Place of Birth: Home Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Risdone 0.5 mg 1 tab HS Investigations done- Hearing assessment: Done Details: BERA- B/l normal 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: 5 months Sitting without support: Achieved Age of attainment: 6 mo nths Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 12 months 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: Following commands: 1-step 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: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Doesnt sit ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Goes to toilet by himself Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Royal world school Grade: Nursery Hours spent in school: 2.5 hours Location: D D Nagar Diet History: Food allergies: Yes Sleep History Total sleep duration (night): 6-7 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: IDP 3/week +PMT 1/week Evaluation: ISAA, DSM 5 ASD (Later) Investigations: Fragile X (TP PCR)- later Medications: Syp Risnia (1mg/ml) 0. 5 ml HS at evening 8 PM Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 17-Apr-2026 03:02PM Demographic Details

Child's Name: Prabal Tomar
Age: 4 Year
Gender: Male
DOB: 2022-03-19
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 29 years
Father’s occupation: Army (Poonch)
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 1 month -/*9/
Address: D D Nagar
Contact: 8450888959
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Hyperactivity, Poor human interaction

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Dengue in 2nd trimester in mother- admitted for 4 days

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Risdone 0.5 mg 1 tab HS Investigations done-

Hearing assessment: Done Details: BERA- B/l normal 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: 5 months
Sitting without support: Achieved

Age of attainment: 6 mo nths
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 12 months

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:
Following commands: 1-step

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: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Doesnt sit

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 1. Dependent
Undressing: 2. Started attempting

Details:: Goes to toilet by himself

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Royal world school
Grade: Nursery
Hours spent in school: 2.5 hours
Location: D D Nagar

Diet History:

Food allergies: Yes

Sleep History

Total sleep duration (night): 6-7 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Proper

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

Impression: ASD

Advice

Intervention plan: IDP 3/week +PMT 1/week
Evaluation: ISAA, DSM 5 ASD (Later)
Investigations: Fragile X (TP PCR)- later
Medications: Syp Risnia (1mg/ml) 0. 5 ml HS at evening 8 PM
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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