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Patient Details


OPD : 16-Jun-2026 01:25PM Demographic Details Child's Name: Atharv Tiwari Age: 2 Year 4 Month 7 Days Gender: Male DOB: 2024-02-09 Mother’s age (years): 27 years Mother’s occupation: Housewife Father’s age (years): 32 years Father’s occupation: Aditya Birla Type of family: Joint Number of family members: 4 Address: Jhansi Contact: 8851105753 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Lines up object, running to and fro, spinning Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Encopresis Sensory Concerns: Tactile: Hypersensitive Auditory: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Avoids swings Details:: Doesnt like messy things to touch and eat 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): Leaking PV Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: No Others: Admitted for dengue and AGE 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: 3 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 7 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 12 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 months Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 18 months Pointing: Achieved Age of attainment: 2 years Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Details:: Started speaking kinship words, says mummum Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Attempts Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 12 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: Dosnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 1. Dependent Details:: Gives cues- comes down from bed Type of Play : 5. Associative Details:: Plays hide and seek Academic History: Is child enrolled in school: No Diet History: Food preferences: Eats food in puree form Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: No Duration of Afternoon nap: 1-2 hours Sleep disturbances: Daily Screen Time Duration: <30 minutes Type of screen: 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 CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: Home Based Program Evaluation: Later General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 16-Jun-2026 01:25PM Demographic Details

Child's Name: Atharv Tiwari
Age: 2 Year 4 Month 7 Days
Gender: Male
DOB: 2024-02-09
Mother’s age (years): 27 years
Mother’s occupation: Housewife
Father’s age (years): 32 years
Father’s occupation: Aditya Birla
Type of family: Joint
Number of family members: 4
Address: Jhansi
Contact: 8851105753
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Lines up object, running to and fro, spinning Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Encopresis
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hyposensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Avoids swings

Details:: Doesnt like messy things to touch and eat

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): Leaking PV
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: No Others: Admitted for dengue and AGE

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: 3 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 7 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 12 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 months

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 18 months
Pointing: Achieved

Age of attainment: 2 years
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Details:: Started speaking kinship words, says mummum

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 12 months
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: Dosnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Details:: Gives cues- comes down from bed

Type of Play : 5. Associative Details:: Plays hide and seek Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Eats food in puree form
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: No
Duration of Afternoon nap: 1-2 hours
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes
Type of screen: 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

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

Impression: ASD

Advice

Intervention plan: Home Based Program
Evaluation: Later
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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