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OPD : 15-Jun-2026 11:18AM Demographic Details Child's Name: Elvin Age: 1 Year 10 Month 22 Days Gender: Male DOB: 2024-07-24 Mother’s age (years): 29 years Mother’s occupation: homemaker Father’s age (years): 30 years Father’s occupation: Govt Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Bhind Contact: 7047034603 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, poor eye contact, poor response to name call Duration of symptoms: Since early infancy Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): MSL Gestational Age: FT Birth Weight: 3.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: Frequent episodes of diarrhea in infancy Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months (Partial) Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 9 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 14 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 month Scribbling: Not achieved Drinking from cup: 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: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Emerging Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved 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: 0/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Predominantly milk. Needs force feeding. Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Sleep disturbances: Yes Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: 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: Improper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: M chat R score- 15 (High risk) CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/week Follow up plan: every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Jun-2026 11:18AM Demographic Details

Child's Name: Elvin
Age: 1 Year 10 Month 22 Days
Gender: Male
DOB: 2024-07-24
Mother’s age (years): 29 years
Mother’s occupation: homemaker
Father’s age (years): 30 years
Father’s occupation: Govt
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Bhind
Contact: 7047034603
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, poor eye contact, poor response to name call
Duration of symptoms: Since early infancy

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

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

Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): MSL
Gestational Age: FT
Birth Weight: 3.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: Frequent episodes of diarrhea in infancy

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

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months (Partial)
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 9 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 14 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 month

Scribbling: Not achieved

Drinking from cup: 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: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent
Drag for needs: Emerging
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved
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: 0/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly milk. Needs force feeding.
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours
Sleep disturbances: Yes

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

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: Improper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

Examination summary: M chat R score- 15 (High risk) CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Follow up plan: every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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