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OPD : 27-Apr-2026 10:20AM Demographic Details Child's Name: Adarsh Shivhare Age: 3 Year 5 Month 2 Days Gender: Male DOB: 2022-11-25 Mother’s age (years): 35 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Govt serice Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Sheopur Contact: 7898867962 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Understanding not as per age Interaction history: Eye contact: Suboptimal Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): stimming Patterned behavior or activities: Inattention Impulsivity Temper tantrums Stubbornness Encopresis Emotional history: Irritability Sensory Concerns: Vestibular: Avoids swings Details:: Sniffs everything. Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: IUI High-risk factors in pregnancy: Ante partum haemorrhage Others:: Conceived after 5 years. H/o PCOD, Hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No If yes- Duration & Indication: On day 2 admitted for NNHB for DSPT for 5-7 days Past history: Hospitalization: Yes Others: Pneumonia at 1 mon age. Admitted for a month. At 2.5 years H/o febrile seizure. Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 6 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 2 year 10 months Walking without support: Achieved Age of attainment: 3 years Running: Achieved Age of attainment: Climbing upstairs: Not achieved Climbing downstairs: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 6 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Not achieved Drinking from cup: Not achieved Buttoning / Unbuttoning: 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: 3 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: 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 Comes when called: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: 2 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours (sometimes) Daily Screen Time Duration: > 2 hours Examination a. Vitals: b. Anthropometry: Weight: 12.6 Kg Height: 94 cm Head circumference: 46 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tendon reflexes: KJ - 2+/2+, AJ 1+/1+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Balance coordination concerns, fine motor difficulties, mild hypotonia CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD ? ASD. M chat R score 14 Advice Intervention plan: HBP 1 /week Evaluation: DQ (VSMs, DST), ISAA, DSM5 ASD Investigations: MRI Brain (Later) Medications: Continue same medications Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 27-Apr-2026 10:20AM Demographic Details

Child's Name: Adarsh Shivhare
Age: 3 Year 5 Month 2 Days
Gender: Male
DOB: 2022-11-25
Mother’s age (years): 35 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Govt serice
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Sheopur
Contact: 7898867962
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Understanding not as per age

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): stimming Patterned behavior or activities: Inattention Impulsivity Temper tantrums Stubbornness Encopresis Emotional history:
Irritability
Sensory Concerns:

Vestibular: Avoids swings

Details:: Sniffs everything.

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: IUI
High-risk factors in pregnancy:
1. Ante partum haemorrhage
Others:: Conceived after 5 years. H/o PCOD, Hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
If yes- Duration & Indication: On day 2 admitted for NNHB for DSPT for 5-7 days

Past history:

Hospitalization: Yes Others: Pneumonia at 1 mon age. Admitted for a month. At 2.5 years H/o febrile seizure.

Investigations done-

Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 6 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 2 year 10 months
Walking without support: Achieved

Age of attainment: 3 years
Running: Achieved

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

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 6 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Not achieved

Drinking from cup: Not achieved

Buttoning / Unbuttoning: 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: 3 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: 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
Comes when called: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: 2 minutes

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours (sometimes)

Daily Screen Time

Duration: > 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.6 Kg Height: 94 cm Head circumference: 46 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tendon reflexes: KJ - 2+/2+, AJ 1+/1+

Oromotor Examination

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

Examination summary: Balance coordination concerns, fine motor difficulties, mild hypotonia CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD ? ASD. M chat R score 14

Advice

Intervention plan: HBP 1 /week
Evaluation: DQ (VSMs, DST), ISAA, DSM5 ASD
Investigations: MRI Brain (Later)
Medications: Continue same medications
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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