Create - Child Development Centre

Patient Details


OPD : 10-Apr-2026 04:11PM Demographic Details Child's Name: Mishita sen Age: 3 Year 11 Month 28 Days Gender: Female DOB: 2022-04-13 Mother’s age (years): 29 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Private job Type of family: Joint Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 8 months male Address: Kampoo Contact: 8959899819 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Poor eye contact, speech delay, hyperactivity Duration of symptoms: Since Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Jumping, to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hyposensitive Visual: Seeks visuals Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: ANC markers- normal. 2 spontaneous abortion (Fallopian tubular abnormality) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Breech presenatation Gestational Age: FT Birth Weight: 2.8Kg Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Syp Cos3, bifolate, nootropil 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: 6 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 11 months Walking without support: Achieved Age of attainment: 12 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 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: Emerging Answering Questions:- Echolalia: Present Social Social smile: Not achieved Stranger anxiety: Not achieved Waving bye bye: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Eats food of her choice on her known Type of Play : 2. Isolated Outdoor play duration: Nil Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Ujjwal Public school Grade: Playgroup Hours spent in school: 3 hours Location: Sikander Kampoo Additional information: Going to have vacations Diet History: Food preferences: Picky eater. Craving for sweets Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 13 Kg Height: 100 cm Head circumference: 49.5 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: IDP 2/week +PMT 1/week Evaluation: ISAA, VSMS DSM 5(later) Medications: Continue as adviced by pediatrician Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 10-Apr-2026 04:11PM Demographic Details

Child's Name: Mishita sen
Age: 3 Year 11 Month 28 Days
Gender: Female
DOB: 2022-04-13
Mother’s age (years): 29 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 8 months male
Address: Kampoo
Contact: 8959899819
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Poor eye contact, speech delay, hyperactivity
Duration of symptoms: Since

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Jumping, to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hyposensitive
Visual: Seeks visuals
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: ANC markers- normal. 2 spontaneous abortion (Fallopian tubular abnormality)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Breech presenatation
Gestational Age: FT
Birth Weight: 2.8Kg
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Syp Cos3, bifolate, nootropil 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: 6 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 11 months
Walking without support: Achieved

Age of attainment: 12 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
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: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Not achieved
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

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

ADL Skills (Age-appropriate)-

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

Details:: Eats food of her choice on her known

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

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Ujjwal Public school
Grade: Playgroup
Hours spent in school: 3 hours
Location: Sikander Kampoo
Additional information: Going to have vacations

Diet History:

Food preferences: Picky eater. Craving for sweets
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 13 Kg Height: 100 cm Head circumference: 49.5 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ASD

Advice

Intervention plan: IDP 2/week +PMT 1/week
Evaluation: ISAA, VSMS DSM 5(later)
Medications: Continue as adviced by pediatrician
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details