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OPD : 06-Jun-2026 03:11PM Demographic Details Child's Name: Bhavishya Verma Age: 15 Year 9 Month 27 Days Gender: Male DOB: 2010-08-10 Mother’s age (years): 37 years Mother’s occupation: Homemaker Father’s age (years): 44 years Father’s occupation: Government teacher Type of family: Nuclear Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 6 year old male Address: Shivpuri Contact: 9755128868 Referred By: Doctor Informant: Father, uncle Presenting Concerns Chief concerns: Understanding not age appropriate Duration of symptoms: Noticed since 3rd grade Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Inattention Impulsivity Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Tactile: Hyposensitive Auditory: Hyposensitive Details:: Sniffs everything 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: Not known Cry at birth: Cried after stimulation Resuscitation required: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Arip, Raspritil 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: 12 months 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: Language Receptive:- Joint attention: Achieved Age of attainment: Pointing: Achieved Age of attainment: 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: 12 months 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Narrates events / stories: Doent prefer long conversation Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Narrates events / stories: Doent prefer long conversation 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:- Able to answer questions: Yes What Where Who Echolalia: Present Social Social smile: Achieved Age of attainment: Stranger anxiety: Achieved Age of attainment: Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Details:: Requires nagging Type of Play : 4. Parallel Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Shiksha Bharti Balniketan School Grade: 10 Hours spent in school: 5 hours Board: MP Location: Shivpuri Additional information: Doesnt study. No behavioral issues at school. Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Frequent Sleep History Total sleep duration (night): 8-9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: 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 CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ID Advice Intervention plan: IEP 2/week + PMT 1/week Evaluation: IQ, Academic evaluation Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 06-Jun-2026 03:11PM Demographic Details

Child's Name: Bhavishya Verma
Age: 15 Year 9 Month 27 Days
Gender: Male
DOB: 2010-08-10
Mother’s age (years): 37 years
Mother’s occupation: Homemaker
Father’s age (years): 44 years
Father’s occupation: Government teacher
Type of family: Nuclear
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 6 year old male
Address: Shivpuri
Contact: 9755128868
Referred By: Doctor
Informant: Father, uncle

Presenting Concerns

Chief concerns: Understanding not age appropriate
Duration of symptoms: Noticed since 3rd grade

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Inattention Impulsivity Stubbornness Aggression Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hyposensitive

Details:: Sniffs everything

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: Not known
Cry at birth: Cried after stimulation
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Arip, Raspritil 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: 12 months

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:

Language

Receptive:-

Joint attention: Achieved

Age of attainment:
Pointing: Achieved

Age of attainment:
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: 12 months

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Narrates events / stories: Doent prefer long conversation

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Narrates events / stories: Doent prefer long conversation

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:-

Able to answer questions: Yes What Where Who Echolalia: Present

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Achieved

Age of attainment:
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Details:: Requires nagging

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Shiksha Bharti Balniketan School
Grade: 10
Hours spent in school: 5 hours
Board: MP
Location: Shivpuri
Additional information: Doesnt study. No behavioral issues at school.

Diet History:

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

Sleep History

Total sleep duration (night): 8-9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

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

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

Impression: ID

Advice

Intervention plan: IEP 2/week + PMT 1/week
Evaluation: IQ, Academic evaluation
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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