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Patient Details


OPD : 02-Jun-2026 10:58AM Demographic Details Child's Name: Ankush Rajavat Age: 4 Year 9 Month 19 Days Gender: Male DOB: 2021-07-15 Mother’s occupation: Teacher Father’s occupation: Govt service Type of family: Nuclear Number of family members: 2 Number of siblings: 1 Details of siblings (Age and sex): 12 year old female Contact: 8889626917 Referred By: Doctor Informant: Mother, maternal uncle Presenting Concerns Chief concerns: Hyperactivity, poor response to name call, poor interaction Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Tactile: Hyposensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: h/o cough- medications taken for 6 months. H/o 2 spontaneous abortion Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: BERA- Left ear- Minimal HL, Right ear- normal 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: 6 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: Hopping: Achieved Age of attainment: Standing on one foot: 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: 3 years 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: 3 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 3 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent 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: Not achieved Response to Name Call Details: 4/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Frequent Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: No Daily Screen Time Duration: < 2 hours 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: 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 Medications: Syp Sizodon 0.2 ml at evening 7 PM. syp IQ norm 5 ml OD Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 02-Jun-2026 10:58AM Demographic Details

Child's Name: Ankush Rajavat
Age: 4 Year 9 Month 19 Days
Gender: Male
DOB: 2021-07-15
Mother’s occupation: Teacher
Father’s occupation: Govt service
Type of family: Nuclear
Number of family members: 2
Number of siblings: 1
Details of siblings (Age and sex): 12 year old female
Contact: 8889626917
Referred By: Doctor
Informant: Mother, maternal uncle

Presenting Concerns

Chief concerns: Hyperactivity, poor response to name call, poor interaction

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Tactile: Hyposensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: h/o cough- medications taken for 6 months. H/o 2 spontaneous abortion

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: BERA- Left ear- Minimal HL, Right ear- normal 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: 6 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:
Hopping: Achieved

Age of attainment:
Standing on one foot: 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: 3 years

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: 3 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 3 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
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: Not achieved

Response to Name Call

Details: 4/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed diet
Food allergies: No
Junk food intake: Frequent

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: No

Daily Screen Time

Duration: < 2 hours
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: 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
Medications: Syp Sizodon 0.2 ml at evening 7 PM. syp IQ norm 5 ml OD
Follow up plan: Every 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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