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OPD : 09-Jul-2026 03:20PM Demographic Details Child's Name: Prasa Tomar Age: 4 Year 6 Month 3 Days Gender: Female DOB: 2022-01-06 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Farming Type of family: Joint Number of siblings: 1 Details of siblings (Age and sex): 7yf, 3yf Address: Ambah Contact: 9691495744 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity Duration of symptoms: Noticed since 1 year Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Details:: Doesnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Home Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: 4 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: 9 months Walking without support: Achieved Age of attainment: 12 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 Drinking from cup: 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: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 2 years 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:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Doesnt sit ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Toilet training: 4. Needs minimal assistance Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Type of Play : 4. Parallel 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): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: <30 minutes Type of screen: Mobile Examination a. Vitals: b. Anthropometry: Weight: 15.6 Kg Height: 99 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: Proper Sucking: Proper Examination summary: Understanding present, interaction good, impulsivity, attention seeking, Pallor+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ADHD Advice Intervention plan: IDP 2/week + PMt 1/week. Diet as adviced. Evaluation: DQ, DSM 5 ADHD Investigations: CBC, Thyroid profile, Vitamin D, Calcium, Vitamin B12, S Lead Follow up plan: After investigations General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 09-Jul-2026 03:20PM Demographic Details

Child's Name: Prasa Tomar
Age: 4 Year 6 Month 3 Days
Gender: Female
DOB: 2022-01-06
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Farming
Type of family: Joint
Number of siblings: 1
Details of siblings (Age and sex): 7yf, 3yf
Address: Ambah
Contact: 9691495744
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity
Duration of symptoms: Noticed since 1 year

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Details:: Doesnt cooperate for haircut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: 4 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: 9 months
Walking without support: Achieved

Age of attainment: 12 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

Drinking from cup: 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: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 2 years

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:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Doesnt sit

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Toilet training: 4. Needs minimal assistance
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Type of Play : 4. Parallel 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): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

Weight: 15.6 Kg Height: 99 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: Proper
Sucking: Proper

Examination summary: Understanding present, interaction good, impulsivity, attention seeking, Pallor+ CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ? ADHD

Advice

Intervention plan: IDP 2/week + PMt 1/week. Diet as adviced.
Evaluation: DQ, DSM 5 ADHD
Investigations: CBC, Thyroid profile, Vitamin D, Calcium, Vitamin B12, S Lead
Follow up plan: After investigations
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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