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OPD : 09-Apr-2026 11:50AM Demographic Details Child's Name: Krishna sukla Age: 22 Year 5 Month 26 Days Gender: Male DOB: 2003-10-14 Mother’s age (years): 48 years Mother’s occupation: Homemaker Father’s age (years): 54 years Father’s occupation: In share market Type of family: Joint Number of family members: 2 Number of siblings: 1 Details of siblings (Age and sex): 15 year male Address: Thatipur Contact: 9202137924 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Dependent in ADLs, Social delay Duration of symptoms: Realized concerns at 2.5 years. Consulted mutiple doctors Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Running to and fro, jumping Patterned behavior or activities: Inattention Impulsivity Defiance Insisting on sameness Stubbornness Aggression Self injurious behaviors Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive 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: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 2 days NICU stay for NNHB Past history: Hospitalization: Yes Seizures: Yes Others: Seizures (GTCS) started at 4 years age. Last episode in January Past/Current therapies: 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 Roll over: Achieved Age of attainment: 11 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 16 months Walking without support: Achieved Age of attainment: 18 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 9 months Unidextrous grasp: Achieved Age of attainment: 10 months Pincer grasp: Achieved Age of attainment: 12 months Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Delayed Pointing: Achieved Age of attainment: Delayed Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: Inconsistent Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: Inconsistent Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Pointing: Consistent meaningful pointing Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: Stranger anxiety: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Type of Play : 1. Unoccupied Academic History: Is child enrolled in school: No Type of school: Regular Additional information: Discontinued- went to Ehsaas school for 5 years Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Head circumference: 56 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns 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: PMT 1/week Investigations: CBC, LFT, Vit D, Vit B12, Calcium, RBS, HBA1C, Thyroid profile, S Triglycerides, S. Cholesterol Medications: Continue Tab Sizodon 0.5 mg BD, Syp Epilex 5 ml TDS General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 09-Apr-2026 11:50AM Demographic Details

Child's Name: Krishna sukla
Age: 22 Year 5 Month 26 Days
Gender: Male
DOB: 2003-10-14
Mother’s age (years): 48 years
Mother’s occupation: Homemaker
Father’s age (years): 54 years
Father’s occupation: In share market
Type of family: Joint
Number of family members: 2
Number of siblings: 1
Details of siblings (Age and sex): 15 year male
Address: Thatipur
Contact: 9202137924
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Dependent in ADLs, Social delay
Duration of symptoms: Realized concerns at 2.5 years. Consulted mutiple doctors

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Running to and fro, jumping Patterned behavior or activities: Inattention Impulsivity Defiance Insisting on sameness Stubbornness Aggression Self injurious behaviors
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive

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: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 2 days NICU stay for NNHB

Past history:

Hospitalization: Yes Seizures: Yes Others: Seizures (GTCS) started at 4 years age. Last episode in January

Past/Current therapies: 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
Roll over: Achieved

Age of attainment: 11 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 16 months
Walking without support: Achieved

Age of attainment: 18 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 9 months

Unidextrous grasp: Achieved

Age of attainment: 10 months

Pincer grasp: Achieved

Age of attainment: 12 months

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delayed
Pointing: Achieved

Age of attainment: Delayed
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: Inconsistent

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: Inconsistent

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Pointing: Consistent meaningful pointing

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Type of Play : 1. Unoccupied Academic History:

Is child enrolled in school: No
Type of school: Regular
Additional information: Discontinued- went to Ehsaas school for 5 years

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Head circumference: 56 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

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: PMT 1/week
Investigations: CBC, LFT, Vit D, Vit B12, Calcium, RBS, HBA1C, Thyroid profile, S Triglycerides, S. Cholesterol
Medications: Continue Tab Sizodon 0.5 mg BD, Syp Epilex 5 ml TDS
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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