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OPD : 01-May-2026 05:24PM Demographic Details Child's Name: Kuldeep Sharma Age: 12 Year 4 Month 21 Days Gender: Male DOB: 2013-12-10 Number of siblings: 3 Details of siblings (Age and sex): 1nd- 17y, 2nd- 15 y. 3rd-14y (females) Address: Joura Contact: 7999884752 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Stammering Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: 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: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: Yes Others: 2 episodes of febrile seizures (at 1 , 1.5 years age). At 9 years GTCS, associated with fever. AEDs given for 3 years. 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: Roll over: Achieved Age of attainment: Sitting without support: Achieved Age of attainment: Standing without support: Achieved Age of attainment: Walking without support: Achieved Age of attainment: Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Standing on one foot: Achieved Age of attainment: Skipping: Achieved Age of attainment: Fine Motor Bidextrous grasp: Achieved Age of attainment: Unidextrous grasp: Achieved Age of attainment: Pincer grasp: Achieved Age of attainment: 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: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 3-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 1.5 years Meaningful words: Achieved Age of attainment: 5 years 2 word Phrases: Achieved Age of attainment: 6 years Complete sentences: Achieved Age of attainment: 7 years Narrates events / stories: Able to narrate stories but stammering+ Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 1.5 years Meaningful words: Achieved Age of attainment: 5 years 2 word Phrases: Achieved Age of attainment: 6 years Complete sentences: Achieved Age of attainment: 7 years Narrates events / stories: Able to narrate stories but stammering+ Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 3-step Answering Questions:- What Where Who Why Echolalia: Absent Patterned speech: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Copying parents in tasks: Achieved Age of attainment: 15 months Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Type of Play : 6. Cooperative Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Soldier School Grade: 7 Hours spent in school: 5 hours Board: MP Location: Joura Any change of school: No Additional information: Tuitions- 1 hour Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: Occasional Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Oriented to time, place, person Memory: Intact Repetition: Stammering + Naming: Intact Voice: Normal Judgement: Intact Insight: Present Sensory Examination Touch: Present Pain: Present Temperature: Present 2-point discrimination: Present Stereognosis: Present Graphesthesia: Present Proprioception: Present Cranial Nerves (1–12) Olfactory nerve: NAD Optic Nerve: NAD cculomotor, Trochlear, Abducent: NAD Trigeminal Nerve: NAD Facial Nerve: NAD Vestibulocochlear Nerve: NAD Glossopharyngeal Nerve: NAD Vagus Nerve: NAD Spinal Accessory: NAD Hypoglossal Nerve: NAD Neuromuscular Concerns Tone: Normal Power: Normal Deep tendon reflexes: KJ 2+/2+, AJ-2+/2+ Superficial reflexes: Present Gait issues: Nil Posture issues: Nil Cerebellar examination: Normal Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Stuttering Advice Intervention plan: Home startegies adviced. Plan to be given after evaluation. Evaluation: IQ, Speech evaluation Medications: As adviced by pediatrician General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 01-May-2026 05:24PM Demographic Details

Child's Name: Kuldeep Sharma
Age: 12 Year 4 Month 21 Days
Gender: Male
DOB: 2013-12-10
Number of siblings: 3
Details of siblings (Age and sex): 1nd- 17y, 2nd- 15 y. 3rd-14y (females)
Address: Joura
Contact: 7999884752
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Stammering

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

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: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: Yes Others: 2 episodes of febrile seizures (at 1 , 1.5 years age). At 9 years GTCS, associated with fever. AEDs given for 3 years.

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:
Roll over: Achieved

Age of attainment:
Sitting without support: Achieved

Age of attainment:
Standing without support: Achieved

Age of attainment:
Walking without support: Achieved

Age of attainment:
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:
Standing on one foot: Achieved

Age of attainment:
Skipping: Achieved

Age of attainment:

Fine Motor

Bidextrous grasp: Achieved

Age of attainment:

Unidextrous grasp: Achieved

Age of attainment:

Pincer grasp: Achieved

Age of attainment:

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: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 3-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 1.5 years

Meaningful words: Achieved

Age of attainment: 5 years

2 word Phrases: Achieved

Age of attainment: 6 years

Complete sentences: Achieved

Age of attainment: 7 years

Narrates events / stories: Able to narrate stories but stammering+

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 1.5 years

Meaningful words: Achieved

Age of attainment: 5 years

2 word Phrases: Achieved

Age of attainment: 6 years

Complete sentences: Achieved

Age of attainment: 7 years

Narrates events / stories: Able to narrate stories but stammering+

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 3-step

Answering Questions:-

What Where Who Why Echolalia: Absent Patterned speech: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Copying parents in tasks: Achieved

Age of attainment: 15 months
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Type of Play : 6. Cooperative Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Soldier School
Grade: 7
Hours spent in school: 5 hours
Board: MP
Location: Joura
Any change of school: No
Additional information: Tuitions- 1 hour

Diet History:

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

Sleep History

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

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Oriented to time, place, person
Memory: Intact
Repetition: Stammering +
Naming: Intact
Voice: Normal
Judgement: Intact
Insight: Present

Sensory Examination

Touch: Present
Pain: Present
Temperature: Present
2-point discrimination: Present
Stereognosis: Present
Graphesthesia: Present
Proprioception: Present

Cranial Nerves (1–12)

Olfactory nerve: NAD
Optic Nerve: NAD
cculomotor, Trochlear, Abducent: NAD
Trigeminal Nerve: NAD
Facial Nerve: NAD
Vestibulocochlear Nerve: NAD
Glossopharyngeal Nerve: NAD
Vagus Nerve: NAD
Spinal Accessory: NAD
Hypoglossal Nerve: NAD

Neuromuscular Concerns

Tone: Normal
Power: Normal
Deep tendon reflexes: KJ 2+/2+, AJ-2+/2+
Superficial reflexes: Present
Gait issues: Nil
Posture issues: Nil

Cerebellar examination: Normal
Oromotor Examination

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

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

Impression: Stuttering

Advice

Intervention plan: Home startegies adviced. Plan to be given after evaluation.
Evaluation: IQ, Speech evaluation
Medications: As adviced by pediatrician
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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