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OPD : 06-May-2026 03:51PM Demographic Details Child's Name: Yashika yadav Age: 4 Year 10 Month 12 Days Gender: Female DOB: 2021-06-24 Mother’s age (years): 31 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Pediatrician Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1- 12 mon male Address: Morar Contact: 8770876931 Referred By: Doctor Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Others Emotional History Details: Irrelevant laughing and crying Sensory Concerns: Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement 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): IUGR Gestational Age: 38 wks Birth Weight: 2.2 kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 2 days for TTN Past history: Hospitalization: No Seizures: No Past/Current therapies: Since 2 years- Speech, OT days/week Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 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: 12 months Walking without support: Achieved Age of attainment: 20 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: 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: Achieved Age of attainment: 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 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: Inconsistent Drag for needs: Consistent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 3. Needs significant assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Indicates for urine and stool Type of Play : 2. Isolated Outdoor play duration: Nil Details:: Cycling Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Blu orchid school Grade: LKG Hours spent in school: 3 hours Location: Morar Diet History: Food preferences: Avoids foods which are hard Food allergies: No Junk food intake: Biscuits occasional Sleep History Total sleep duration (night): 8-10 hours Afternoon nap: No 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 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 Evaluation: DQ, ISAA, DSM5 ASD General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-May-2026 03:51PM Demographic Details

Child's Name: Yashika yadav
Age: 4 Year 10 Month 12 Days
Gender: Female
DOB: 2021-06-24
Mother’s age (years): 31 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Pediatrician
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1- 12 mon male
Address: Morar
Contact: 8770876931
Referred By: Doctor

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

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

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

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): IUGR
Gestational Age: 38 wks
Birth Weight: 2.2 kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 2 days for TTN

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Since 2 years- Speech, OT days/week Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: BERA- normal Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 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: 12 months
Walking without support: Achieved

Age of attainment: 20 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: 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: Achieved

Age of attainment:
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

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: Inconsistent
Drag for needs: Consistent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Details:: Indicates for urine and stool

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

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Blu orchid school
Grade: LKG
Hours spent in school: 3 hours
Location: Morar

Diet History:

Food preferences: Avoids foods which are hard
Food allergies: No
Junk food intake: Biscuits occasional

Sleep History

Total sleep duration (night): 8-10 hours
Afternoon nap: No

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

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
Evaluation: DQ, ISAA, DSM5 ASD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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