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OPD : 21-May-2026 10:04AM Demographic Details Child's Name: Harshit Dhakad Age: 4 Year 3 Month 10 Days Gender: Male DOB: 2022-02-11 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Teacher Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Anand Nagar, Gwalior Contact: 8085222700 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): spinning, jumpingstimming Patterned behavior or activities: Inattention Impulsivity Object obsession Mouthing of objects Sensory Concerns: Details:: Cooperates for haircut and nailcut Birth & Perinatal History: Antenatal History Consanguinity: Yes Type of conception: Natural High-risk factors in pregnancy: PIH Others:: Hyperemesis gravidarum. H/o 1 still birth at 8 months gestation Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.75 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: At 1.5 years h/o stiffening of body after execissive crying ? Breatholding spell ? seizure. NO episodes after that Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: OAE- pass, BERA- normal 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: 10 months Walking without support: Achieved Age of attainment: 12 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: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: 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: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 2-4 minutes For tasks: More tasks ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 4. Needs minimal assistance Toilet training: 3. Needs significant assistance Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Details:: Doesnt indicate for stools Type of Play : 4. Parallel Details:: Plays hide and seek Academic History: Is child enrolled in school: No Additional information: Discontinued Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Height: 100 cm Head circumference: 50 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: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 1/week + LDP 1/week + PMT 1/week Evaluation: ISAA, DSM5 ASD, Language and speech evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 21-May-2026 10:04AM Demographic Details

Child's Name: Harshit Dhakad
Age: 4 Year 3 Month 10 Days
Gender: Male
DOB: 2022-02-11
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Teacher
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Anand Nagar, Gwalior
Contact: 8085222700
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): spinning, jumpingstimming Patterned behavior or activities: Inattention Impulsivity Object obsession Mouthing of objects
Sensory Concerns:

Details:: Cooperates for haircut and nailcut

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
Others:: Hyperemesis gravidarum. H/o 1 still birth at 8 months gestation

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.75 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: At 1.5 years h/o stiffening of body after execissive crying ? Breatholding spell ? seizure. NO episodes after that

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: OAE- pass, BERA- normal

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: 10 months
Walking without support: Achieved

Age of attainment: 12 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: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
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: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 2-4 minutes
For tasks: More tasks

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 4. Needs minimal assistance
Toilet training: 3. Needs significant assistance
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Details:: Doesnt indicate for stools

Type of Play : 4. Parallel Details:: Plays hide and seek Academic History:

Is child enrolled in school: No
Additional information: Discontinued

Diet History:

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

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Height: 100 cm Head circumference: 50 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: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Advice

Intervention plan: IDP 1/week + LDP 1/week + PMT 1/week
Evaluation: ISAA, DSM5 ASD, Language and speech evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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