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OPD : 11-Jun-2026 11:10AM Demographic Details Child's Name: Jiyanshi Rathore Age: 2 Year 8 Month 16 Days Gender: Female DOB: 2023-09-26 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Advocate Type of family: Joint Number of family members: 17 Number of siblings: 0 Address: shivpuri Contact: 9826670996 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, spinning, tapping face Patterned behavior or activities: Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Emotional history: Irritability Sensory Concerns: Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Avoids swings Details:: Movement seeking Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural 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 NICU stay: No Past history: Hospitalization: No Seizures: No Others: Admitted 2-3 times for AGE (Lactose free) Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Not done Family history: Neuropsychiatric condition: No Others: Hepatitis B in father 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: 10 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: Hopping: 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 Drinking from cup: Achieved Age of attainment: 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 Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved 2 word Phrases: 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: Achieved Age of attainment: Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5-7 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Drags to toilet for urination. not for stools Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater. Sugar cravings Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Sleep disturbances: Daily Screen Time Duration: > 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 Cafe au lait macule d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: Yes 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 + PMT 1/week Follow up plan: after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 11-Jun-2026 11:10AM Demographic Details

Child's Name: Jiyanshi Rathore
Age: 2 Year 8 Month 16 Days
Gender: Female
DOB: 2023-09-26
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Advocate
Type of family: Joint
Number of family members: 17
Number of siblings: 0
Address: shivpuri
Contact: 9826670996
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, spinning, tapping face Patterned behavior or activities: Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Emotional history:
Irritability
Sensory Concerns:

Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Avoids swings

Details:: Movement seeking

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

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
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: Admitted 2-3 times for AGE (Lactose free)

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

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

Family history:

Neuropsychiatric condition: No Others: Hepatitis B in father

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: 10 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:
Hopping: 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

Drinking from cup: Achieved

Age of attainment:

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

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

2 word Phrases: 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: Achieved

Age of attainment:

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5-7 minutes

ADL Skills (Age-appropriate)-

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

Details:: Drags to toilet for urination. not for stools

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater. Sugar cravings
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours
Sleep disturbances:

Daily Screen Time

Duration: > 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 Cafe au lait macule

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: Yes
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 + PMT 1/week
Follow up plan: after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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