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OPD : 03-Apr-2026 12:28PM Demographic Details Child's Name: Ishan Sharma Age: 3 Year 4 Month 28 Days Gender: Male DOB: 2022-11-06 Mother’s age (years): 33 years Mother’s occupation: Clerk in PHE Father’s age (years): 37 years Father’s occupation: MPEB, Bhind Type of family: Joint Number of family members: 4 Number of siblings: 0 Address: Bhind Contact: 6232914812 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Object obsession Sensory Concerns: Tactile: Hyposensitive Auditory: Hyposensitive Details:: Tactile seeking- blankets Birth & Perinatal History: Antenatal History Consanguinity: Yes Type of conception: Natural Others:: 2 spontaneous abortion (1st at 4 weeks and 2nd at 12 weeks) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Others: At 10 month- seizures were noted. EEG was done- normal. Valpraote was started. Going on since thenAdmitted once at 6 month for AGE. Past/Current medications: Syp Valance currently 2.5 ml BD ( Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: Speech delay in paternal cousin 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 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 16 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: 15 months Language Receptive:- Joint attention: Achieved Age of attainment: 3 years (Inconsistent) Pointing: Not achieved Understanding gestures: Not achieved Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 month Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 month Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Comes when called: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Details: 6-8/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: More for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Brainy bears Grade: Playgroup Hours spent in school: 3 hoursery Location: Bhind Diet History: Food allergies: No Junk food intake: Occasionally Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 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 Tone: Normal Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: Home Based Program General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 03-Apr-2026 12:28PM Demographic Details

Child's Name: Ishan Sharma
Age: 3 Year 4 Month 28 Days
Gender: Male
DOB: 2022-11-06
Mother’s age (years): 33 years
Mother’s occupation: Clerk in PHE
Father’s age (years): 37 years
Father’s occupation: MPEB, Bhind
Type of family: Joint
Number of family members: 4
Number of siblings: 0
Address: Bhind
Contact: 6232914812
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Object obsession
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hyposensitive

Details:: Tactile seeking- blankets

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
Type of conception: Natural
Others:: 2 spontaneous abortion (1st at 4 weeks and 2nd at 12 weeks)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Others: At 10 month- seizures were noted. EEG was done- normal. Valpraote was started. Going on since thenAdmitted once at 6 month for AGE.

Past/Current medications: Syp Valance currently 2.5 ml BD ( Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: Speech delay in paternal cousin

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 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 16 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: 15 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 3 years (Inconsistent)
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 month

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 month

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye:
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Details: 6-8/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: More for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Brainy bears
Grade: Playgroup
Hours spent in school: 3 hoursery
Location: Bhind

Diet History:

Food allergies: No
Junk food intake: Occasionally

Sleep History

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

Tone: Normal

Oromotor Examination

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

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

Impression: ASD

Advice

Intervention plan: Home Based Program
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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