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OPD : 18-Jul-2026 05:43PM Demographic Details Child's Name: Roopchand Rajpoot Age: 4 Year 10 Month 0 Days Gender: Male DOB: 2021-09-18 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Farmer Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 8 year old female Address: Mahoba Contact: 9219536981 Referred By: Doctor Informant: Parents Behavioral history: Hyperactivity Inattention Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: No ANC visits Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Prolonged labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Delayed cry Resuscitation required: No NICU stay: No If yes- Duration & Indication: ? Delayed cry Past history: Hospitalization: Yes Seizures: Yes Others: h/o seizures since 1 year age., multiple episodes since then, ? focal , not associatiated with fever, no LOC Past/Current medications: Phenytoin, valparin 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: 6 months Sitting without support: Achieved Age of attainment: 12 months Standing without support: Achieved Age of attainment: 3.5 year Walking without support: Achieved Age of attainment: 3.5 years 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: 3 years Unidextrous grasp: Achieved Age of attainment: after 3 years Pincer grasp: Not achieved Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: Not known Pointing: Achieved Age of attainment: Not known Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3.5 years Babbling: Achieved Age of attainment: 4 years Meaningful words: Achieved Age of attainment: Limited Expressive:- Cooing: Achieved Age of attainment: 3.5 years Babbling: Achieved Age of attainment: 4 years Meaningful words: Achieved Age of attainment: Limited Details:: Kinship words started 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 Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 years Stranger anxiety: Achieved Age of attainment: 3.5 years Waving bye bye: Not achieved Comes when called: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 2-3 minutes For tasks: 5 minutes ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 3. Onlooker 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): 11 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 16 Kg Height: 103 cm Head circumference: 50 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Advice Intervention plan: Home strategies adviced General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-Jul-2026 05:43PM Demographic Details

Child's Name: Roopchand Rajpoot
Age: 4 Year 10 Month 0 Days
Gender: Male
DOB: 2021-09-18
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 8 year old female
Address: Mahoba
Contact: 9219536981
Referred By: Doctor
Informant: Parents

Behavioral history:

Hyperactivity Inattention

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: No ANC visits

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Prolonged labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Delayed cry
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: ? Delayed cry

Past history:

Hospitalization: Yes Seizures: Yes Others: h/o seizures since 1 year age., multiple episodes since then, ? focal , not associatiated with fever, no LOC

Past/Current medications: Phenytoin, valparin 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: 6 months
Sitting without support: Achieved

Age of attainment: 12 months
Standing without support: Achieved

Age of attainment: 3.5 year
Walking without support: Achieved

Age of attainment: 3.5 years
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: 3 years

Unidextrous grasp: Achieved

Age of attainment: after 3 years

Pincer grasp: Not achieved

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Not known
Pointing: Achieved

Age of attainment: Not known
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3.5 years

Babbling: Achieved

Age of attainment: 4 years

Meaningful words: Achieved

Age of attainment: Limited

Expressive:-

Cooing: Achieved

Age of attainment: 3.5 years

Babbling: Achieved

Age of attainment: 4 years

Meaningful words: Achieved

Age of attainment: Limited

Details:: Kinship words started

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
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 years
Stranger anxiety: Achieved

Age of attainment: 3.5 years
Waving bye bye: Not achieved
Comes when called: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 2-3 minutes
For tasks: 5 minutes

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 3. Onlooker 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): 11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

Weight: 16 Kg Height: 103 cm Head circumference: 50 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Advice

Intervention plan: Home strategies adviced
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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