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OPD : 06-Jul-2026 10:46AM Demographic Details Child's Name: Tanush Shakya Age: 1 Year 11 Month 11 Days Gender: Male DOB: 2024-07-16 Mother’s age (years): 40 years Mother’s occupation: Homemaker Father’s age (years): 40 years Father’s occupation: MPEB Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 6 years Address: Sheel Nagar Contact: 9893349857 Referred By: Doctor Informant: Mother Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): spinning Patterned behavior or activities: Inattention Object obsession Temper tantrums Stubbornness Others Emotional History Details: Irrelevant laughing Sensory Concerns: Visual: Seeks visuals Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Hypotension. Poor appetite during pregnancy. Poor weight gain. H/o 3 spontaneous abortions Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: Late PT Birth Weight: 2.95 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 2 days for NNHB Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Brainmax, Rubired 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: 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: 8 months Walking without support: Achieved Age of attainment: 9 months 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 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 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: 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: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: 2-5 minutes For tasks: 5-7 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 2. Started attempting 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 Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: Irregular Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 11 Kg Height: 88 cm Head circumference: 49 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: ab 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 Others: Prefers solid food CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD. M chat R score- 15 (High risk) Advice Intervention plan: HBP 1/week General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-Jul-2026 10:46AM Demographic Details

Child's Name: Tanush Shakya
Age: 1 Year 11 Month 11 Days
Gender: Male
DOB: 2024-07-16
Mother’s age (years): 40 years
Mother’s occupation: Homemaker
Father’s age (years): 40 years
Father’s occupation: MPEB
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 6 years
Address: Sheel Nagar
Contact: 9893349857
Referred By: Doctor
Informant: Mother

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

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

Visual: Seeks visuals

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Hypotension. Poor appetite during pregnancy. Poor weight gain. H/o 3 spontaneous abortions

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: Late PT
Birth Weight: 2.95 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 2 days for NNHB

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Brainmax, Rubired 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: 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: 8 months
Walking without support: Achieved

Age of attainment: 9 months
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

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

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: 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: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: 2-5 minutes
For tasks: 5-7 minutes

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 2. Started attempting
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
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: Irregular
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg Height: 88 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: ab

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
Others: Prefers solid food

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

Impression: ? ASD. M chat R score- 15 (High risk)

Advice

Intervention plan: HBP 1/week
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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