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OPD : 09-Jun-2026 11:50AM Demographic Details Child's Name: Shiva Tomar Age: 4 Year 9 Month 18 Days Gender: Male DOB: 2021-07-17 Contact: 7489177440 Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Inattention Others Emotional History Details: Irrelevant laughing+ 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: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Cued pointing Understanding gestures: Absent Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5 minutes ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Type of Play : 3. Onlooker Outdoor play duration: Irregular Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: 2 times/week Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 30 minutes Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: 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: ASD Advice Intervention plan: IDP 2/week Investigations: EEG, Whole Exome Sequencing, Fragile X TP- PCR, MRI Brain (in view of cafe au lait) Medications: Syp IQ norm DHA 5 ml BD, Syp vibrocar 5 ml BD Follow up plan: every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 09-Jun-2026 11:50AM Demographic Details

Child's Name: Shiva Tomar
Age: 4 Year 9 Month 18 Days
Gender: Male
DOB: 2021-07-17
Contact: 7489177440

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Inattention Others Emotional History Details: Irrelevant laughing+

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: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Cued pointing
Understanding gestures: Absent
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5 minutes

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Type of Play : 3. Onlooker Outdoor play duration: Irregular Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 30 minutes

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

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: ASD

Advice

Intervention plan: IDP 2/week
Investigations: EEG, Whole Exome Sequencing, Fragile X TP- PCR, MRI Brain (in view of cafe au lait)
Medications: Syp IQ norm DHA 5 ml BD, Syp vibrocar 5 ml BD
Follow up plan: every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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