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OPD : 25-Apr-2026 01:29PM Demographic Details Child's Name: Samyak Gautam Age: 4 Year 4 Month 21 Days Gender: Male DOB: 2021-12-04 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Govt job Type of family: Joint Number of family members: 4 Number of siblings: 0 Address: Suresh Nagar Contact: 9926222231 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Stares from corner of eye Patterned behavior or activities: Hyperactivity Inattention Impulsivity Stubbornness 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): Cord around neck Gestational Age: FT Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: OT + Special education - since 9 months Past/Current medications: Homeopathic medicines 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: 10 months 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 Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 8 months Pointing: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 1.5 years 2 word Phrases: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 1.5 years 2 word Phrases: Achieved Age of attainment: 2 years Communication & Language Assessment Non-Verbal Communication Grading:- Pointing: Consistent meaningful pointing Understanding gestures: Consistent 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: 8 months Comes when called: Achieved Age of attainment: Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 3. Needs significant assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: once in 2-3 days Sleep History Total sleep duration (night): 10-12 hours Afternoon nap: Yes Duration of Afternoon nap: 1-1.5 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Height: 106 cm Head circumference: 51 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 1/week + PMT 1/week Evaluation: DQ (VSMS + DST) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 25-Apr-2026 01:29PM Demographic Details

Child's Name: Samyak Gautam
Age: 4 Year 4 Month 21 Days
Gender: Male
DOB: 2021-12-04
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Govt job
Type of family: Joint
Number of family members: 4
Number of siblings: 0
Address: Suresh Nagar
Contact: 9926222231
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Stares from corner of eye Patterned behavior or activities: Hyperactivity Inattention Impulsivity Stubbornness

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): Cord around neck
Gestational Age: FT
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: OT + Special education - since 9 months Past/Current medications: Homeopathic medicines 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: 10 months

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

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 8 months
Pointing: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 1.5 years

2 word Phrases: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 1.5 years

2 word Phrases: Achieved

Age of attainment: 2 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
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: 8 months
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5 minutes

ADL Skills (Age-appropriate)-

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

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: once in 2-3 days

Sleep History

Total sleep duration (night): 10-12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-1.5 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Height: 106 cm Head circumference: 51 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: ?ASD

Advice

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

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