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OPD : 16-Jul-2026 01:43PM Demographic Details Child's Name: Shivansh Singh Tomar Age: 2 Year 3 Month 2 Days Gender: Male DOB: 2024-02-02 Contact: 9806709042 Interaction history: Eye contact: Fleeting Interaction: Improved with parents Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Object obsession Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Details:: Reduced Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- 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 Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: 2 minutes For tasks: 2-3 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 3. Onlooker Outdoor play duration: 2 hours Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 13Kg Head circumference: 48 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week + PMT 1/15 days Medications: Syp Autinorm 5 ml OD Follow up plan: every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 16-Jul-2026 01:43PM Demographic Details

Child's Name: Shivansh Singh Tomar
Age: 2 Year 3 Month 2 Days
Gender: Male
DOB: 2024-02-02
Contact: 9806709042

Interaction history:

Eye contact: Fleeting
Interaction: Improved with parents
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Object obsession
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

Details:: Reduced

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

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

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: 2 minutes
For tasks: 2-3 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 3. Onlooker Outdoor play duration: 2 hours Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 13Kg Head circumference: 48 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper

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

Advice

Intervention plan: IDP 2/week + PMT 1/15 days
Medications: Syp Autinorm 5 ml OD
Follow up plan: every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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