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OPD : 18-May-2026 05:45PM Demographic Details Child's Name: Madhav Yadav Age: 2 Year 8 Month 7 Days Gender: Male DOB: 2023-09-07 Mother’s age (years): 36 years Mother’s occupation: Homemaker Father’s age (years): 39 years Father’s occupation: Govt teacher Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 6.5 year old female Address: Itawa Contact: 9479693599 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity Interaction history: Eye contact: Suboptimal Quality of Interaction: age-appropriate Behavioral history: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Sensory Concerns: Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Previous LSCS Gestational Age: 38 weeks Birth Weight: 3.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: ! day for NNHB under PT 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: 3 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 10 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 Scribbling: Achieved Age of attainment: 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: 16 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 16 months Details:: Current vocabulary- mumma, puppa, baba, de do, hat jao Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Answering Questions:- Patterned speech: Present 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 Details: 7-8/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: better for tasks ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: 1-2 hours 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): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1.5 hours Sleep disturbances: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 12.4Kg Height: 88 cm Head circumference: 47 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: Ab 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 Impression: M chat R score- 1 (Low risk) Advice Evaluation: DQ, ISAA, DSM 5ADHD General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-May-2026 05:45PM Demographic Details

Child's Name: Madhav Yadav
Age: 2 Year 8 Month 7 Days
Gender: Male
DOB: 2023-09-07
Mother’s age (years): 36 years
Mother’s occupation: Homemaker
Father’s age (years): 39 years
Father’s occupation: Govt teacher
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 6.5 year old female
Address: Itawa
Contact: 9479693599
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: age-appropriate

Behavioral history:

Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness
Sensory Concerns:

Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Previous LSCS
Gestational Age: 38 weeks
Birth Weight: 3.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: ! day for NNHB under PT

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: 3 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 10 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

Scribbling: Achieved

Age of attainment:

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: 16 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 16 months

Details:: Current vocabulary- mumma, puppa, baba, de do, hat jao

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging

Answering Questions:-

Patterned speech: Present

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

Details: 7-8/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: better for tasks

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 2. Isolated Outdoor play duration: 1-2 hours 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): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1.5 hours
Sleep disturbances: No

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.4Kg Height: 88 cm Head circumference: 47 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: Ab

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

Impression: M chat R score- 1 (Low risk)

Advice

Evaluation: DQ, ISAA, DSM 5ADHD
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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