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OPD : 11-Jul-2026 11:36AM Demographic Details Child's Name: Ilham Khan Age: 4 Year 1 Month 2 Days Gender: Male DOB: 2022-05-07 Contact: 9149210209 Interaction history: Eye contact: Fleeting Interaction: Interaction improved with parents Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Avoids swings Details:: Concerns reduced. Compliance reduced Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Emerging Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: 2-5 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Doesnt indicate for urine and stool Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: 1-2/week Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 18 Kg Height: 109 cm Head circumference: 51 cm c. General Examination 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: Improvement in interaction, eye contact, response to name call Advice Intervention plan: HBP 1/week . IDP when possible Evaluation: DQ, ISAA, DSM5 ASD Medications: Syp risperidone (1mg/ml) 0.5 ml HS Follow up plan: Every months General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 11-Jul-2026 11:36AM Demographic Details

Child's Name: Ilham Khan
Age: 4 Year 1 Month 2 Days
Gender: Male
DOB: 2022-05-07
Contact: 9149210209

Interaction history:

Eye contact: Fleeting
Interaction: Interaction improved with parents
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession
Sensory Concerns:

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

Details:: Concerns reduced. Compliance reduced

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Emerging
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: 2-5 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Details:: Doesnt indicate for urine and stool

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: 1-2/week

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 18 Kg Height: 109 cm Head circumference: 51 cm

c. General Examination

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: Improvement in interaction, eye contact, response to name call

Advice

Intervention plan: HBP 1/week . IDP when possible
Evaluation: DQ, ISAA, DSM5 ASD
Medications: Syp risperidone (1mg/ml) 0.5 ml HS
Follow up plan: Every months
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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