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Demographic Details Child's Name: Abhay Sharma Age: 8 Year 3 Month 19 Days Gender: Male DOB: 2017-11-04 Mother’s age (years): 43 years Mother’s occupation: Homemaker Father’s age (years): 44 years Father’s occupation: Ex defence personnel Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Adityapuram Contact: 9646611604 Referred By: Doctor Strengths of child: Understanding not age appropriate Behavioral history: Repetitive behaviors (RRBs): Handflapping Inattention Impulsivity Stubbornness Aggression Academic Concerns: Poor scholastic performance Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: Late PT Birth Weight: 1.9 Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Nicu stay- 1 month. Ventilator- 12 days Past history: Hospitalization: No Seizures: No Others: Recurrent cough and cold Investigations done- Hearing assessment: Done Details: Reports not there Vision assessment: Done Details: Reports not there Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 8 months Roll over: Achieved Age of attainment: 10 months Sitting without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 2.5 years Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 14 months Pincer grasp: Achieved Age of attainment: 15 months Scribbling: Achieved Age of attainment: 24 months Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 5 years Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 9 months Babbling: Achieved Age of attainment: 10 months Meaningful words: Achieved Age of attainment: 2.5 years 2 word Phrases: Achieved Age of attainment: 3 years Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 9 months Babbling: Achieved Age of attainment: 10 months Meaningful words: Achieved Age of attainment: 2.5 years 2 word Phrases: Achieved Age of attainment: 3 years Complete sentences: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 1-step Answering Questions:- What Where Who Echolalia: Absent Social Social smile: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 12 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: continuously fidgets ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 3. Needs significant assistance Undressing: 3. Needs significant assistance Type of Play : 3. Onlooker Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Little wings Grade: 1 Hours spent in school: 5 hrs (9am) to 2pm Location: Adityapuram Additional information: 3 days regular school, 3 days Roshani Diet History: Food preferences: Picky eating Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: No Daily Screen Time Duration: > 5 hours Examination a. Vitals: b. Anthropometry: Weight: 23 Kg c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Power: Normal Deep tandon reflexes: DTR- KJ 3+/3+, AJ 2+/2+ Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IQ testing, DSM5 ADHD, Language and speech evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Abhay Sharma
Age: 8 Year 3 Month 19 Days
Gender: Male
DOB: 2017-11-04
Mother’s age (years): 43 years
Mother’s occupation: Homemaker
Father’s age (years): 44 years
Father’s occupation: Ex defence personnel
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Adityapuram
Contact: 9646611604
Referred By: Doctor

Strengths of child: Understanding not age appropriate

Behavioral history:

Repetitive behaviors (RRBs): Handflapping Inattention Impulsivity Stubbornness Aggression Academic Concerns:
Poor scholastic performance

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: Late PT
Birth Weight: 1.9 Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- 1 month. Ventilator- 12 days

Past history:

Hospitalization: No Seizures: No Others: Recurrent cough and cold

Investigations done-

Hearing assessment: Done Details: Reports not there Vision assessment: Done Details: Reports not there

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 8 months
Roll over: Achieved

Age of attainment: 10 months
Sitting without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 2.5 years

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 14 months

Pincer grasp: Achieved

Age of attainment: 15 months

Scribbling: Achieved

Age of attainment: 24 months

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 5 years
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

Babbling: Achieved

Age of attainment: 10 months

Meaningful words: Achieved

Age of attainment: 2.5 years

2 word Phrases: Achieved

Age of attainment: 3 years

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 9 months

Babbling: Achieved

Age of attainment: 10 months

Meaningful words: Achieved

Age of attainment: 2.5 years

2 word Phrases: Achieved

Age of attainment: 3 years

Complete sentences: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 1-step

Answering Questions:-

What Where Who Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 12 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: continuously fidgets

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 3. Needs significant assistance
Undressing: 3. Needs significant assistance

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Little wings
Grade: 1
Hours spent in school: 5 hrs (9am) to 2pm
Location: Adityapuram
Additional information: 3 days regular school, 3 days Roshani

Diet History:

Food preferences: Picky eating
Food allergies: No

Sleep History

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

Daily Screen Time

Duration: > 5 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 23 Kg

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Power: Normal
Deep tandon reflexes: DTR- KJ 3+/3+, AJ 2+/2+

Oromotor Examination

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

Advice

Intervention plan: IQ testing, DSM5 ADHD, Language and speech evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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