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Yesterday
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Patient Details
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OPD :
12-May-2026 03:40PM
Demographic Details
Child's Name
:
Aradhya Pal
Age
:
3 Year
Gender
:
Female
DOB
:
2023-04-20
Mother’s age (years)
:
27 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
27 years
Father’s occupation
:
Compounder
Type of family
:
Joint
Number of family members
:
8
Number of siblings
:
1
Details of siblings (Age and sex)
:
9 months female
Address
:
Morar
Contact
:
8770829334
Referred By
:
Doctor
Informant
:
Parents
Presenting Concerns
Chief concerns
:
Poor response to name call
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
Emotional history:
Irritability
Sensory Concerns:
Tactile
:
Hyposensitive
Auditory
:
Hypersensitive
Visual
:
Seeks visuals
Proprioception
:
Seeks pressure
Vestibular
:
Seeks movement
Details:
:
Doesnt cooperate for nailcut
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
Natural
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
NVD
Gestational Age
:
FT
Birth Weight
:
2.8 Kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
Others
:
H/o frequent episodes of AGE
Past/Current therapies
:
Nil
Past/Current medications
:
homeopathic medications
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
Roll over
:
Achieved
Age of attainment
:
5 months
Sitting without support
:
Achieved
Age of attainment
:
6 months
Standing without support
:
Achieved
Age of attainment
:
9 months
Walking without support
:
Achieved
Age of attainment
:
12 months
Running
:
Not achieved
Climbing upstairs
:
Not achieved
Fine Motor
Bidextrous grasp
:
Achieved
Age of attainment
:
4 months
Unidextrous grasp
:
Achieved
Age of attainment
:
5 months
Pincer grasp
:
Achieved
Age of attainment
:
12 months
Scribbling
:
Not achieved
Drinking from cup
:
Not achieved
Language
Receptive:-
Joint attention
:
Achieved
Age of attainment
:
Pointing
:
Achieved
Age of attainment
:
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
Answering Questions:-
Echolalia
:
Present
Social
Social smile
:
Achieved
Age of attainment
:
2 months
Stranger anxiety
:
Not achieved
Waving bye bye
:
Not achieved
Response to Name Call
Details
:
1/10
Sitting tolerance- (in minutes)
For interaction
:
doesnt sit
For tasks
:
1-2 minutes
ADL Skills (Age-appropriate)-
Eating
:
2. Started attempting
Bathing
:
1. Dependent
Toilet training
:
1. Dependent
Dressing
:
2. Started attempting
Undressing
:
1. Dependent
Details:
:
Indicates for stool by cues, touches genitals
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
No
Diet History:
Food preferences
:
Picky eater
Food allergies
:
No
Sleep History
Total sleep duration (night)
:
7-8 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
3 hours
Sleep disturbances
:
Daily Screen Time
Duration
:
Zero
Examination
a. Vitals:
b. Anthropometry:
c. General Examination
d. CNS:
Higher Mental Functions
Sensory Examination
Cranial Nerves (1–12)
Neuromuscular Concerns
Oromotor Examination
Drooling
:
No
Chewing
:
Proper
Swallowing
:
Proper
Blowing
:
Improper
Sucking
:
Improper
CVS examination
:
NAD
Respiratory System examination
:
NAD
Per abdomen examination
:
NAD
Impression
:
ASD. M chat R- 16 (High risk)
Advice
Intervention plan
:
IDP 2/week + PMT 1/week
Evaluation
:
DQ, ISAA, DSM5 ASD
Follow up plan
:
After 1month
General recommendation-
Zero Screen Time
Physical interactive play
No Junk food
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