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OPD : 08-Jun-2026 12:12PM Demographic Details Child's Name: yashdeep sharma Age: 13 Year 4 Month 5 Days Gender: Male DOB: 2013-02-03 Mother’s age (years): 44 years Mother’s occupation: Homemaker Father’s age (years): 44 years Father’s occupation: State bank of India Type of family: Nuclear Number of siblings: 1 Details of siblings (Age and sex): 17 years Address: Adityapuram Contact: 9009420042 Referred By: Relative Informant: Father Presenting Concerns Chief concerns: fine motor difficulties, reasoning Duration of symptoms: Noticed at 3 years age Interaction history: Eye contact: Suboptimal Interaction: Interaction better with brother Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Stubbornness Aggression Emotional history: Lack of emotions Lack of interest Others Emotional History Details: When unengaged repetitive behaviors Sensory Concerns: Auditory: Fear of loud sounds Details:: Unable to do nailcutting by himself. Goes for haircutting by himself 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 immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: H/o allergies 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: 3 months Roll over: Achieved Age of attainment: 4 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: Hopping: Achieved Age of attainment: Standing on one foot: 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: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 2 years Pointing: Achieved Age of attainment: 2.5 years Understanding gestures: Achieved Age of attainment: Following commands: 2-step Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Not achieved Details:: Tries speaking complete sentences breaking in 2 word phrases Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) For interaction: 30 minutes For tasks: Can sit for longer periods ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 3. Needs significant assistance Toilet training: 5. Independent Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Details:: Can prepare maggi. Eats by spoon well. Unable to do buttoning, unbuttoning. difficulty in applying soap. Type of Play : 3. Onlooker Outdoor play duration: Nil Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Central Academy School Grade: 8 Hours spent in school: 4 Board: CBSE Location: Adityapuram Diet History: Food preferences: Mixed Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: c. General Examination 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 Advice Intervention plan: After evaluations Evaluation: IQ evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Jun-2026 12:12PM Demographic Details

Child's Name: yashdeep sharma
Age: 13 Year 4 Month 5 Days
Gender: Male
DOB: 2013-02-03
Mother’s age (years): 44 years
Mother’s occupation: Homemaker
Father’s age (years): 44 years
Father’s occupation: State bank of India
Type of family: Nuclear
Number of siblings: 1
Details of siblings (Age and sex): 17 years
Address: Adityapuram
Contact: 9009420042
Referred By: Relative
Informant: Father

Presenting Concerns

Chief concerns: fine motor difficulties, reasoning
Duration of symptoms: Noticed at 3 years age

Interaction history:

Eye contact: Suboptimal
Interaction: Interaction better with brother
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Inattention Impulsivity Stubbornness Aggression Emotional history:
Lack of emotions Lack of interest Others Emotional History Details: When unengaged repetitive behaviors
Sensory Concerns:

Auditory: Fear of loud sounds

Details:: Unable to do nailcutting by himself. Goes for haircutting by himself

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 immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: H/o allergies

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: 3 months
Roll over: Achieved

Age of attainment: 4 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:
Hopping: Achieved

Age of attainment:
Standing on one foot: 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:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 2 years
Pointing: Achieved

Age of attainment: 2.5 years
Understanding gestures: Achieved

Age of attainment:
Following commands: 2-step

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Not achieved

Details:: Tries speaking complete sentences breaking in 2 word phrases

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 30 minutes
For tasks: Can sit for longer periods

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 3. Needs significant assistance
Toilet training: 5. Independent
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Details:: Can prepare maggi. Eats by spoon well. Unable to do buttoning, unbuttoning. difficulty in applying soap.

Type of Play : 3. Onlooker Outdoor play duration: Nil Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Central Academy School
Grade: 8
Hours spent in school: 4
Board: CBSE
Location: Adityapuram

Diet History:

Food preferences: Mixed
Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: No

Daily Screen Time

Duration: > 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

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

Advice

Intervention plan: After evaluations
Evaluation: IQ evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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