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OPD : 02-May-2026 04:24PM Demographic Details Child's Name: Aditya Dhakad Age: 7 Year 11 Month 20 Days Gender: Male DOB: 2018-05-12 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Farmer Type of family: Joint Number of family members: 6 Number of siblings: 2 Details of siblings (Age and sex): 1- 11.5 y female, 2- 10 year female Address: Sabalgarh Contact: 6267442026 Referred By: Doctor Informant: Maternal uncle (Mama) Presenting Concerns Chief concerns: Understanding as per age Duration of symptoms: Since early infancy Interaction history: Eye contact: Suboptimal Interaction: prefers playing with young kids Quality of Interaction: avoids Behavioral history: Inattention Stubbornness Aggression Emotional history: Irritability Academic Concerns: Poor scholastic performance Difficulty in reading Difficulty in writing Difficulty in mathematics Poor recall of learnt material Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: Late PT Birth Weight: 4.25Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: Epilepsy in maternal uncle Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Achieved Age of attainment: 10 months Standing without support: Achieved Age of attainment: 4 years Walking without support: Achieved Age of attainment: 4 years 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: Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: 4 years Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 5 years 2 word Phrases: Achieved Age of attainment: 6 years Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 5 years 2 word Phrases: Achieved Age of attainment: 6 years Complete sentences: Not achieved Details:: Expresses if gets hurt, or anyone hit Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- What Echolalia: Absent Patterned speech: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 5 years Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 5. Independent Toilet training: 5. Independent Dressing: 4. Needs minimal assistance Undressing: 5. Independent Details:: Toilet training completed by 5 years age. Doesnt understand front and back. Type of Play : 4. Parallel Details:: Doesnt understand simple games Academic History: Is child enrolled in school: Yes Type of school: Regular Grade: 1 Hours spent in school: 5 hours Location: Sabalgarh Additional information: Forgets lessons. Tuitions- 1.5 hours Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: Infrequent naps Daily Screen Time Duration: < 1 hour Type of screen: Mobile and TV Examination a. Vitals: HR: 96/min RR: 24/min Temperature: afebrile b. Anthropometry: Weight: 21 Kg Height: 128 cm Head circumference: 51 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Evaluation: IQ evaluation Investigations: CBC, Iron profile, Calcium, Thyroid profile, S vit D2, S. Vit B12 Medications: Continue as adviced by pediatrician General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-May-2026 04:24PM Demographic Details

Child's Name: Aditya Dhakad
Age: 7 Year 11 Month 20 Days
Gender: Male
DOB: 2018-05-12
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 6
Number of siblings: 2
Details of siblings (Age and sex): 1- 11.5 y female, 2- 10 year female
Address: Sabalgarh
Contact: 6267442026
Referred By: Doctor
Informant: Maternal uncle (Mama)

Presenting Concerns

Chief concerns: Understanding as per age
Duration of symptoms: Since early infancy

Interaction history:

Eye contact: Suboptimal
Interaction: prefers playing with young kids
Quality of Interaction: avoids

Behavioral history:

Inattention Stubbornness Aggression Emotional history:
Irritability Academic Concerns:
Poor scholastic performance Difficulty in reading Difficulty in writing Difficulty in mathematics Poor recall of learnt material

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: Late PT
Birth Weight: 4.25Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: Epilepsy in maternal uncle

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Achieved

Age of attainment: 4 years
Walking without support: Achieved

Age of attainment: 4 years
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:

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment: 4 years
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment: 5 years

2 word Phrases: Achieved

Age of attainment: 6 years

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment: 5 years

2 word Phrases: Achieved

Age of attainment: 6 years

Complete sentences: Not achieved

Details:: Expresses if gets hurt, or anyone hit

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

What Echolalia: Absent Patterned speech: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 5 years
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 4. Needs minimal assistance
Undressing: 5. Independent

Details:: Toilet training completed by 5 years age. Doesnt understand front and back.

Type of Play : 4. Parallel Details:: Doesnt understand simple games Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Grade: 1
Hours spent in school: 5 hours
Location: Sabalgarh
Additional information: Forgets lessons. Tuitions- 1.5 hours

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No
Duration of Afternoon nap: Infrequent naps

Daily Screen Time

Duration: < 1 hour
Type of screen: Mobile and TV

Examination

a. Vitals:

HR: 96/min RR: 24/min Temperature: afebrile

b. Anthropometry:

Weight: 21 Kg Height: 128 cm Head circumference: 51 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Proper

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

Advice

Evaluation: IQ evaluation
Investigations: CBC, Iron profile, Calcium, Thyroid profile, S vit D2, S. Vit B12
Medications: Continue as adviced by pediatrician
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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