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OPD : 16-Apr-2026 11:35AM Demographic Details Child's Name: Anas Khan Age: 2 Year 9 Month 20 Days Gender: Male DOB: 2023-06-27 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 25 years Father’s occupation: Private job Type of family: Joint Number of family members: 7 Number of siblings: 1 Details of siblings (Age and sex): 1.5 years old male Address: Sabalgarh Contact: 9886309099 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor response to name call Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 2 Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: 1st cousin 12 year old has ? ID 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: 7 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 11 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 1/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: Nil Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky allergy Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hours Sleep disturbances: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 11 Kg Height: 90 cm Head circumference: 49.5 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 1*).5 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: M Chat R Score- 15 CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 1/week + PMT 1/week Medications: Syp IQ norm 5 ml OD, Syp Sizodon (1mg/ml) 0.1 ml HS at evening 7 PM Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 16-Apr-2026 11:35AM Demographic Details

Child's Name: Anas Khan
Age: 2 Year 9 Month 20 Days
Gender: Male
DOB: 2023-06-27
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 25 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 7
Number of siblings: 1
Details of siblings (Age and sex): 1.5 years old male
Address: Sabalgarh
Contact: 9886309099
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor response to name call

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 2

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: BERA- normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: 1st cousin 12 year old has ? ID

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: 7 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 11 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 1/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Less than a minute

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: Nil Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky allergy
Food allergies: No
Junk food intake: Daily

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hours
Sleep disturbances: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg Height: 90 cm Head circumference: 49.5 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: 1 cafe au lait macule 1*).5 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

Examination summary: M Chat R Score- 15 CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ?ASD

Advice

Intervention plan: IDP 1/week + PMT 1/week
Medications: Syp IQ norm 5 ml OD, Syp Sizodon (1mg/ml) 0.1 ml HS at evening 7 PM
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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