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OPD : 21-Apr-2026 02:17PM Demographic Details Child's Name: Hridayansh Sehgal Age: 4 Year 9 Month 10 Days Gender: Male DOB: 2021-07-11 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Business Number of family members: 7 Number of siblings: 1 Details of siblings (Age and sex): 5 months male Address: Aazamgarh Contact: 7047412523 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, impulsivity Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: 1 spontaneous abortion at 8 weeks (after this pregnancy) 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: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Was admitted for 5 days for Respiratory distress Past history: Hospitalization: No Seizures: No 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: 5 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: 13 months 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 Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 2 years Understanding gestures: Achieved Age of attainment: Expressive:- Babbling: Achieved Age of attainment: 8 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 3 years Expressive:- Babbling: Achieved Age of attainment: 8 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 3 years Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Emerging Pointing: Attempts Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Comes when called: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Less than a minute ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 2. Started attempting Toilet training: 4. Needs minimal assistance Dressing: 1. Dependent Undressing: 1. Dependent Details:: Needs assistance for cleaning stool Type of Play : 2. Isolated Details:: Destructive play Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Little flower School Grade: LKG Hours spent in school: 4.5 hours Location: Azamgarh, UP Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week +PMT 1/week Evaluation: ISAA, DSM 5ASD, DSM5 ADHD (Later) Investigations: CBC, Calcium, Vitamin D2, Vitamin B12, S Lead, S. Homocysteine Thyroid profile Medications: Syp IQ norm 5 ml BD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 21-Apr-2026 02:17PM Demographic Details

Child's Name: Hridayansh Sehgal
Age: 4 Year 9 Month 10 Days
Gender: Male
DOB: 2021-07-11
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Business
Number of family members: 7
Number of siblings: 1
Details of siblings (Age and sex): 5 months male
Address: Aazamgarh
Contact: 7047412523
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, impulsivity

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: 1 spontaneous abortion at 8 weeks (after this pregnancy)

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: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Was admitted for 5 days for Respiratory distress

Past history:

Hospitalization: No Seizures: No

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: 5 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: 13 months

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

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 2 years
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 3 years

Expressive:-

Babbling: Achieved

Age of attainment: 8 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 3 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Emerging
Pointing: Attempts

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved
Comes when called: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Less than a minute

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 2. Started attempting
Toilet training: 4. Needs minimal assistance
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Needs assistance for cleaning stool

Type of Play : 2. Isolated Details:: Destructive play Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Little flower School
Grade: LKG
Hours spent in school: 4.5 hours
Location: Azamgarh, UP

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Daily

Sleep History

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

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Advice

Intervention plan: IDP 2/week +PMT 1/week
Evaluation: ISAA, DSM 5ASD, DSM5 ADHD (Later)
Investigations: CBC, Calcium, Vitamin D2, Vitamin B12, S Lead, S. Homocysteine Thyroid profile
Medications: Syp IQ norm 5 ml BD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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