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OPD : 11-Jul-2026 04:00PM Demographic Details Child's Name: lakshit Raguwanshi Age: 6 Year 7 Month 7 Days Gender: Male DOB: 2019-12-04 Address: Shivpuri Contact: 8770745343 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Social interaction deficit Duration of symptoms: Noticed at 9 months age Interaction history: Eye contact: Suboptimal Interaction: Wants to play in his own way Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): toe walking Inattention Impulsivity Object obsession Stubbornness Aggression Mouthing of objects Being bullied Emotional history: Irritability Others Emotional History Details: Gets irritated if someone is laughing, feels people laughing on him; understanding of emotions there Academic Concerns: Details:: No complaints from school Sensory Concerns: Vestibular: Avoids swings Details:: Earlier was hypersensitive to sound and light Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Hyperemesis gravidarum Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Cord around neck Gestational Age: FT Birth Weight: 2.9 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: At age 2.5 years admitted for vomiting Investigations done- Hearing assessment: Done Details: OAE- pass/pass 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: 10 months Walking without support: Achieved Age of attainment: 13 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 Scribbling: Achieved Age of attainment: 18 months Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Achieved Age of attainment: 5 years Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 2-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Not remembered 2 word Phrases: Achieved Age of attainment: Not remembered Complete sentences: Achieved Age of attainment: not remembered Narrates events / stories: Tries to narrate stories Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Not remembered 2 word Phrases: Achieved Age of attainment: Not remembered Complete sentences: Achieved Age of attainment: not remembered Narrates events / stories: Tries to narrate stories Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 2-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 2.5 years Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Delayed Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: 10 minutes For tasks: 30 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 5. Independent Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 5. Associative Outdoor play duration: Indulges in frequent fights Details:: understands rules of simple games Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Doon Public School Grade: 1 Hours spent in school: 4 hours Board: CBSE Location: Shivpuri Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours 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: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Poor self regulation Advice Evaluation: ISAA, DSM5 ASD, CBCL, BASC Follow up plan: After evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 11-Jul-2026 04:00PM Demographic Details

Child's Name: lakshit Raguwanshi
Age: 6 Year 7 Month 7 Days
Gender: Male
DOB: 2019-12-04
Address: Shivpuri
Contact: 8770745343
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Social interaction deficit
Duration of symptoms: Noticed at 9 months age

Interaction history:

Eye contact: Suboptimal
Interaction: Wants to play in his own way
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): toe walking Inattention Impulsivity Object obsession Stubbornness Aggression Mouthing of objects Being bullied Emotional history:
Irritability Others Emotional History Details: Gets irritated if someone is laughing, feels people laughing on him; understanding of emotions there Academic Concerns:
Details:: No complaints from school
Sensory Concerns:

Vestibular: Avoids swings

Details:: Earlier was hypersensitive to sound and light

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Hyperemesis gravidarum

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Cord around neck
Gestational Age: FT
Birth Weight: 2.9 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: At age 2.5 years admitted for vomiting

Investigations done-

Hearing assessment: Done Details: OAE- pass/pass 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: 10 months
Walking without support: Achieved

Age of attainment: 13 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

Scribbling: Achieved

Age of attainment: 18 months

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Achieved

Age of attainment: 5 years

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 2-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: Not remembered

2 word Phrases: Achieved

Age of attainment: Not remembered

Complete sentences: Achieved

Age of attainment: not remembered

Narrates events / stories: Tries to narrate stories

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: Not remembered

2 word Phrases: Achieved

Age of attainment: Not remembered

Complete sentences: Achieved

Age of attainment: not remembered

Narrates events / stories: Tries to narrate stories

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
Following commands (gesture + verbal): 2-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 2.5 years
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment: Delayed

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: 10 minutes
For tasks: 30 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 5. Independent
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 5. Associative Outdoor play duration: Indulges in frequent fights Details:: understands rules of simple games Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Doon Public School
Grade: 1
Hours spent in school: 4 hours
Board: CBSE
Location: Shivpuri

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

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: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: Poor self regulation

Advice

Evaluation: ISAA, DSM5 ASD, CBCL, BASC
Follow up plan: After evaluation
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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