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Welcome to Otika template!
Yesterday
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Patient Details
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OPD :
06-Jun-2026 12:55PM
Demographic Details
Child's Name
:
Samarth Saraswat
Age
:
4 Year 4 Month 20 Days
Gender
:
Male
DOB
:
2022-01-17
Mother’s age (years)
:
32 years
Mother’s occupation
:
Homemaker
Father’s age (years)
:
32 years
Father’s occupation
:
Sports consultant
Type of family
:
Joint
Number of family members
:
5
Number of siblings
:
1
Details of siblings (Age and sex)
:
8 year old female
Address
:
Vinay nagar
Contact
:
8085244668
Referred By
:
Doctor
Informant
:
Parents
Interaction history:
Eye contact
:
Fleeting
Quality of Interaction
:
limited
Behavioral history:
Birth & Perinatal History:
Antenatal History
Consanguinity
:
No
Type of conception
:
Natural
Natal and Postnatal History:
Place of Birth
:
Institutional
Mode of Delivery
:
LSCS
Indication for LSCS (if applicable)
:
Previous LSCS
Gestational Age
:
FT
Birth Weight
:
2.7 Kg
Cry at birth
:
Cried immediately after birth
Resuscitation required
:
No
NICU stay
:
No
Past history:
Hospitalization
:
No
Seizures
:
No
Past/Current therapies
:
ABA* 1year. Speech- 2 years
Past/Current medications
:
Syp Risdone 8 drops
Investigations done-
Hearing assessment
:
Done
Details
:
BERA- normal
Vision assessment
:
Done
Details
:
Normal
Family history:
Developmental History:
Gross Motor
Neck holding
:
Achieved
Age of attainment
:
3 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
:
Language
Receptive:-
Joint attention
:
Achieved
Age of attainment
:
Delayed
Pointing
:
Achieved
Age of attainment
:
Delayed
Understanding gestures
:
Achieved
Age of attainment
:
Following commands
:
1-step
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
Details:
:
Mumma, de do
Communication & Language Assessment
Non-Verbal Communication Grading:-
Need-based communication
:
Consistent
Drag for needs
:
Consistent
Joint attention
:
Emerging
Pointing
:
Absent
Understanding gestures
:
Absent
Following commands (gesture + verbal)
:
1-step
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
Response to Name Call
Details
:
8/10
Sitting tolerance- (in minutes)
For tasks
:
Better for tasks
ADL Skills (Age-appropriate)-
Eating
:
1. Dependent
Bathing
:
2. Started attempting
Toilet training
:
2. Started attempting
Dressing
:
1. Dependent
Undressing
:
2. Started attempting
Details:
:
Eats Dry snacks by himself
Type of Play : 2. Isolated
Academic History:
Is child enrolled in school
:
Yes
Type of school
:
Regular
Name of School
:
DPS
Grade
:
LKG
Hours spent in school
:
3 hours
Diet History:
Food preferences
:
Mixed
Food allergies
:
No
Junk food intake
:
Craving for sugar
Sleep History
Total sleep duration (night)
:
10 hours
Afternoon nap
:
Yes
Duration of Afternoon nap
:
1 hour
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
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
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