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Demographic Details Child's Name: Dishant Sharma Age: 6 Year 2 Month 23 Days Gender: Male DOB: 2020-01-02 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Private job (Aditya Birla) Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 11 year old Contact: 8959461248 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, behavioral concerns Duration of symptoms: Hyperactivity since early infancy Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Sensory Concerns: Vestibular: Seeks movement 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): Obstructed labor Birth Weight: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: No Seizures: No Others: ! year back- admitted for jaundice, recurrent cough cold Past/Current therapies: 1 month speech therapy 1 year back 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: 10 months Walking without support: Achieved Age of attainment: 12 months 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 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: 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: Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- What Where Who Echolalia: Absent 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: Copying parents in tasks: Achieved Age of attainment: Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: better for tasks Details:: Fidgetiness+ ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Details:: Unable to do Unbuttoning and buttoning Type of Play : 5. Associative Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: MJF School Grade: UKG Hours spent in school: 5 years Board: MP Location: Gol pahadiya Diet History: Food preferences: Picky eating Food allergies: No Junk food intake: Biscuits Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule 0.5*1 cm d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tandon reflexes: Tone normal, DTR- normal Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Others: Eats with screens CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Investigations: Evaluations- DQ (VSMS+ DST, Speech and evaluation, DSM5 ASD General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Dishant Sharma
Age: 6 Year 2 Month 23 Days
Gender: Male
DOB: 2020-01-02
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Private job (Aditya Birla)
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 11 year old
Contact: 8959461248
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, behavioral concerns
Duration of symptoms: Hyperactivity since early infancy

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness
Sensory Concerns:

Vestibular: Seeks movement

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): Obstructed labor
Birth Weight: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No Others: ! year back- admitted for jaundice, recurrent cough cold

Past/Current therapies: 1 month speech therapy 1 year back 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: 10 months
Walking without support: Achieved

Age of attainment: 12 months

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
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:

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:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Following commands (gesture + verbal): 1-step

Answering Questions:-

What Where Who Echolalia: Absent

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:
Copying parents in tasks: Achieved

Age of attainment:

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: better for tasks

Details:: Fidgetiness+

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Details:: Unable to do Unbuttoning and buttoning

Type of Play : 5. Associative Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: MJF School
Grade: UKG
Hours spent in school: 5 years
Board: MP
Location: Gol pahadiya

Diet History:

Food preferences: Picky eating
Food allergies: No
Junk food intake: Biscuits

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: No

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: 1 cafe au lait macule 0.5*1 cm

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tandon reflexes: Tone normal, DTR- normal

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper
Others: Eats with screens

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

Advice

Investigations: Evaluations- DQ (VSMS+ DST, Speech and evaluation, DSM5 ASD
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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