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OPD : 06-Apr-2026 11:45AM Demographic Details Child's Name: Vaarad Age: 3 Year 8 Month 18 Days Gender: Male DOB: 2022-07-19 Mother’s age (years): 34 Years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Advocate Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Jhansi Contact: 8009205025 Referred By: Doctor Informant: Parents, grandmother Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): stimmimg Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Sensory Concerns: Auditory: Hyposensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Others:: Neonatal Thyroid screening- Normal Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Cord around neck Gestational Age: FT Birth Weight: 3.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: H/o adenoid hypertrophy Investigations done- Hearing assessment: Done Details: Tympanometry- was done Vision assessment: Not done Family history: Neuropsychiatric condition: No 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: 11 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Achieved Age of attainment: 12 months Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: inconsistent Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Consistent Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: 2-5 min For tasks: More ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: GD Goenka Grade: Toddlers Hours spent in school: 3 hours Board: CBSE Location: Jhansi Diet History: Food preferences: Mixed diet Food allergies: Yes Junk food intake: No Sleep History Total sleep duration (night): 11-12 hours Afternoon nap: No Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 17 Kg Head circumference: 49 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: 2 Cafe au lait spots over thigh d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ 2+/2+, AJ 2+/2+ Superficial reflexes: Plantar- flexors Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ASD Advice Intervention plan: IDP 1/week+ PMT 1/week Evaluation: DQ (VSMS+DST), ISAA, DSM5 ASD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-Apr-2026 11:45AM Demographic Details

Child's Name: Vaarad
Age: 3 Year 8 Month 18 Days
Gender: Male
DOB: 2022-07-19
Mother’s age (years): 34 Years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Advocate
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Jhansi
Contact: 8009205025
Referred By: Doctor
Informant: Parents, grandmother

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): stimmimg Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession
Sensory Concerns:

Auditory: Hyposensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
Others:: Neonatal Thyroid screening- Normal

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Cord around neck
Gestational Age: FT
Birth Weight: 3.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: H/o adenoid hypertrophy

Investigations done-

Hearing assessment: Done Details: Tympanometry- was done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

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: 11 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Achieved

Age of attainment: 12 months

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: inconsistent
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Consistent

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: 2-5 min
For tasks: More

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: GD Goenka
Grade: Toddlers
Hours spent in school: 3 hours
Board: CBSE
Location: Jhansi

Diet History:

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

Sleep History

Total sleep duration (night): 11-12 hours
Afternoon nap: No

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 17 Kg Head circumference: 49 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: 2 Cafe au lait spots over thigh

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: KJ 2+/2+, AJ 2+/2+
Superficial reflexes: Plantar- flexors

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper

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

Impression: ?ASD

Advice

Intervention plan: IDP 1/week+ PMT 1/week
Evaluation: DQ (VSMS+DST), ISAA, DSM5 ASD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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