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OPD : 08-Jun-2026 06:14PM Demographic Details Child's Name: Daniya sainya Age: 4 Year 8 Month 18 Days Gender: Female DOB: 2021-09-21 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Events company Type of family: Nuclear Number of family members: 9 Number of siblings: 1 Details of siblings (Age and sex): 1 year female Address: Lashkar Contact: 9617961539 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Stimmimg running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Others Emotional History Details: Irrelevant laughing Sensory Concerns: Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): PIH Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: Yes Seizures: No Others: Admitted thrice for AGE with dehydration Past/Current medications: Nil 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: 8 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 2 years Walking without support: Achieved Age of attainment: 2.5 years 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: Not achieved Pointing: Not achieved Understanding gestures: 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 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 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: Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 3-5 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Eats with screeens. Eats preferred food by himself. Removes pants when urge to urinate. Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: 2-3 times/week Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Duration of Afternoon nap: 2-4 hours Sleep disturbances: Daily Screen Time Duration: <30 minutes Type of screen: Mobile and TV 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: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 2/week + PMT 1/week Evaluation: DQ, ISAA, DSM5 ASD (Next month) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 08-Jun-2026 06:14PM Demographic Details

Child's Name: Daniya sainya
Age: 4 Year 8 Month 18 Days
Gender: Female
DOB: 2021-09-21
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Events company
Type of family: Nuclear
Number of family members: 9
Number of siblings: 1
Details of siblings (Age and sex): 1 year female
Address: Lashkar
Contact: 9617961539
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Stimmimg running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): PIH
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: Yes Seizures: No Others: Admitted thrice for AGE with dehydration

Past/Current medications: Nil 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: 8 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 2 years
Walking without support: Achieved

Age of attainment: 2.5 years
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: Not achieved
Pointing: Not achieved
Understanding gestures: 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

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 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:
Stranger anxiety: Achieved

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

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 3-5 minutes

ADL Skills (Age-appropriate)-

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

Details:: Eats with screeens. Eats preferred food by himself. Removes pants when urge to urinate.

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-4 hours
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile and TV

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: Improper
Sucking: Improper

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

Impression: ?ASD

Advice

Intervention plan: IDP 2/week + PMT 1/week
Evaluation: DQ, ISAA, DSM5 ASD (Next month)
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

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