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OPD : 09-Jun-2026 04:07PM Demographic Details Child's Name: Ilham Khan Age: 4 Year 1 Month 2 Days Gender: Male DOB: 2022-05-07 Mother’s age (years): 33 years Mother’s occupation: Teacher Father’s age (years): 39 years Father’s occupation: Business Type of family: Joint Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 8.5 years Address: Etawah Contact: 9149210209 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity 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 Others Emotional History Details: Excessive laughing Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Avoids swings Birth & Perinatal History: Antenatal History Consanguinity: No Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Cord around neck, MSL Gestational Age: FT Birth Weight: Above 3 kg Cry at birth: Cried after stimulation Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Home therapies 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: 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: 9 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 Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging 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: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: doesnt sit For tasks: Can sit longer ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: In diapers Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed: sugar cravings Food allergies: No Junk food intake: 2-3 times/week Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 18.75 Kg Height: 108cm Head circumference: 51cm 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 Examination summary: ASD CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: Home based program Evaluation: DQ, ISAA, DSM5 ASD (Later) General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 09-Jun-2026 04:07PM Demographic Details

Child's Name: Ilham Khan
Age: 4 Year 1 Month 2 Days
Gender: Male
DOB: 2022-05-07
Mother’s age (years): 33 years
Mother’s occupation: Teacher
Father’s age (years): 39 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 8.5 years
Address: Etawah
Contact: 9149210209
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity

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 Others Emotional History Details: Excessive laughing
Sensory Concerns:

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

Birth & Perinatal History: Antenatal History

Consanguinity: No

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Cord around neck, MSL
Gestational Age: FT
Birth Weight: Above 3 kg
Cry at birth: Cried after stimulation
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Home therapies 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: 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: 9 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

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
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: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: doesnt sit
For tasks: Can sit longer

ADL Skills (Age-appropriate)-

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

Details:: In diapers

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed: sugar cravings
Food allergies: No
Junk food intake: 2-3 times/week

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 18.75 Kg Height: 108cm Head circumference: 51cm

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

Examination summary: ASD CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ASD

Advice

Intervention plan: Home based program
Evaluation: DQ, ISAA, DSM5 ASD (Later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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