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OPD : 29-Jun-2026 02:40PM Demographic Details Child's Name: Hardik Rai Age: 5 Year 4 Month 4 Days Gender: Male DOB: 2021-02-25 Mother’s age (years): 37 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: shop Type of family: Joint Number of family members: 8 Number of siblings: 0 Address: Motijheel Contact: 9826534999 Referred By: Doctor Informant: Parents Presenting Concerns Duration of symptoms: Noticed 1 year back Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Fear of loud sounds 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): Breech presentation, cord around neck Gestational Age: FT Birth Weight: Not known Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: No Seizures: No 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: 3 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: 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: Unidextrous grasp: Achieved Age of attainment: Pincer grasp: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Delayed Pointing: Achieved Age of attainment: Delayed Understanding gestures: Achieved Age of attainment: Delayed Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Details:: Patterned speech- able to communicate his basic needs Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 12 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 2-4 minutes For tasks: Can sit longer for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 3. Needs significant assistance Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Details:: Indicates for urine and stool inconsistently. Needs assistance for stools. Passes stools in standing posture Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Coccoon Playschool Grade: Playgroup Hours spent in school: 4 hours Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Duration of Afternoon nap: Occasional naps Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 20 Kg Height: 118 cm Head circumference: 51.5 cm 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: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD Advice Intervention plan: IDP 2/week + PMT1/week Evaluation: DQ (VSMS, DST), ISAA, DSM5 ASD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 29-Jun-2026 02:40PM Demographic Details

Child's Name: Hardik Rai
Age: 5 Year 4 Month 4 Days
Gender: Male
DOB: 2021-02-25
Mother’s age (years): 37 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: shop
Type of family: Joint
Number of family members: 8
Number of siblings: 0
Address: Motijheel
Contact: 9826534999
Referred By: Doctor
Informant: Parents

Presenting Concerns

Duration of symptoms: Noticed 1 year back

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Auditory: Fear of loud sounds
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): Breech presentation, cord around neck
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No

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: 3 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: 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:

Unidextrous grasp: Achieved

Age of attainment:

Pincer grasp: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delayed
Pointing: Achieved

Age of attainment: Delayed
Understanding gestures: Achieved

Age of attainment: Delayed
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words:

Details:: Patterned speech- able to communicate his basic needs

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 12 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 2-4 minutes
For tasks: Can sit longer for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 3. Needs significant assistance
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Details:: Indicates for urine and stool inconsistently. Needs assistance for stools. Passes stools in standing posture

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Coccoon Playschool
Grade: Playgroup
Hours spent in school: 4 hours

Diet History:

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

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional naps

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 20 Kg Height: 118 cm Head circumference: 51.5 cm

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: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: ? ASD

Advice

Intervention plan: IDP 2/week + PMT1/week
Evaluation: DQ (VSMS, DST), ISAA, DSM5 ASD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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