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OPD : 15-May-2026 12:34PM Demographic Details Child's Name: Shivay singh Rajawat Age: 8 Year 8 Month 12 Days Gender: Male DOB: 2017-09-03 Contact: 9907399109 Presenting Concerns Chief concerns: Irritability, poor self regulation Interaction history: Eye contact: Sustained Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history: Irritability Academic Concerns: Details:: Talkativeness+, inattention Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Home Mode of Delivery: NVD Gestational Age: FT Birth Weight: 4 Kg Cry at birth: Cried immediately after birth NICU stay: Yes If yes- Duration & Indication: Admitted for NNHB for 5 days Past history: Hospitalization: No Seizures: Yes Others: Febrile seizure at 1.5 years age Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: 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: 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: Skipping: 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: 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: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 18 months Complete sentences: Achieved Age of attainment: 24 months Narrates events / stories: Narrates events 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: 18 months Complete sentences: Achieved Age of attainment: 24 months Narrates events / stories: Narrates events 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 Why When How 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 Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: fidgetiness while interacting For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Type of Play : 6. Cooperative Outdoor play duration: 2 hours Details:: Understands rules of play Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Eastern height public school Grade: 4 Hours spent in school: 6 hours Board: CBSE Location: shivpuri Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: No Sleep disturbances: Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: HR: 92/min RR: 24/min b. Anthropometry: Weight: 26 Kg Height: 142 cm Head circumference: 50 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Oriented to time, place, person Memory: Intact Repetition: Intact Naming: Intact Voice: Intact Judgement: Intact Insight: Intact Perception: Intact Sensory Examination Touch: NAD Pain: NAD Temperature: NAD 2-point discrimination: Present Stereognosis: Present Graphesthesia: Present Proprioception: Present Cranial Nerves (1–12) Olfactory nerve: NAD Optic Nerve: NAD cculomotor, Trochlear, Abducent: NAD Trigeminal Nerve: NAD Facial Nerve: NAD Vestibulocochlear Nerve: NAD Glossopharyngeal Nerve: NAD Vagus Nerve: NAD Spinal Accessory: NAD Hypoglossal Nerve: NAD Neuromuscular Concerns Tone: Normal Power: NAD Deep tendon reflexes: KJ- 3+/3+, AJ- 2+/2+ Superficial reflexes: Present Cerebellar examination: Intact Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Poor self regulation Advice Intervention plan: Home Based Program 1/week Evaluation: DSM5 ADHD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-May-2026 12:34PM Demographic Details

Child's Name: Shivay singh Rajawat
Age: 8 Year 8 Month 12 Days
Gender: Male
DOB: 2017-09-03
Contact: 9907399109

Presenting Concerns

Chief concerns: Irritability, poor self regulation

Interaction history:

Eye contact: Sustained
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history:
Irritability Academic Concerns:
Details:: Talkativeness+, inattention

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 4 Kg
Cry at birth: Cried immediately after birth
NICU stay: Yes
If yes- Duration & Indication: Admitted for NNHB for 5 days

Past history:

Hospitalization: No Seizures: Yes Others: Febrile seizure at 1.5 years age

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: 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: 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:
Skipping: 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: 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: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 18 months

Complete sentences: Achieved

Age of attainment: 24 months

Narrates events / stories: Narrates events

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: 18 months

Complete sentences: Achieved

Age of attainment: 24 months

Narrates events / stories: Narrates events

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 Why When How

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
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: fidgetiness while interacting
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 6. Cooperative Outdoor play duration: 2 hours Details:: Understands rules of play Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Eastern height public school
Grade: 4
Hours spent in school: 6 hours
Board: CBSE
Location: shivpuri

Diet History:

Food preferences: Mixed diet
Food allergies: No
Junk food intake: Daily

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: No
Sleep disturbances:

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

HR: 92/min RR: 24/min

b. Anthropometry:

Weight: 26 Kg Height: 142 cm Head circumference: 50 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Oriented to time, place, person
Memory: Intact
Repetition: Intact
Naming: Intact
Voice: Intact
Judgement: Intact
Insight: Intact
Perception: Intact

Sensory Examination

Touch: NAD
Pain: NAD
Temperature: NAD
2-point discrimination: Present
Stereognosis: Present
Graphesthesia: Present
Proprioception: Present

Cranial Nerves (1–12)

Olfactory nerve: NAD
Optic Nerve: NAD
cculomotor, Trochlear, Abducent: NAD
Trigeminal Nerve: NAD
Facial Nerve: NAD
Vestibulocochlear Nerve: NAD
Glossopharyngeal Nerve: NAD
Vagus Nerve: NAD
Spinal Accessory: NAD
Hypoglossal Nerve: NAD

Neuromuscular Concerns

Tone: Normal
Power: NAD
Deep tendon reflexes: KJ- 3+/3+, AJ- 2+/2+
Superficial reflexes: Present

Cerebellar examination: Intact
Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

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

Impression: Poor self regulation

Advice

Intervention plan: Home Based Program 1/week
Evaluation: DSM5 ADHD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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