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OPD : 19-Aug-2026 03:37PM Demographic Details Child's Name: Gunav Age: 5 Year 10 Month 22 Days Gender: Male DOB: 2020-09-28 Mother’s age (years): 40 years Mother’s occupation: Homemaker Father’s age (years): 42 years Father’s occupation: Business Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Chetakpuri Contact: 9410477727 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Behavioral concerns Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Inattention Temper tantrums Stubbornness Aggression 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): MAlpresentation Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: admitted on day 3 for 2 days for NNHB Past history: Hospitalization: No Seizures: No 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: 9 months Walking without support: Achieved Age of attainment: 14 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: 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: 2-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Delayed Complete sentences: Achieved Age of attainment: Delayed Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: Delayed Complete sentences: Achieved Age of attainment: Delayed 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): 2-step Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 6 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Toilet training: 4. Needs minimal assistance Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Type of Play : 5. Associative Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Seven I Grade: UKG Hours spent in school: 4:30 hours Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 7 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 27 Kg Height: 122 cm Head circumference: 52.5 cm 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 Impression: Behavioral dysregulation Advice Evaluation: BASC General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 19-Aug-2026 03:37PM Demographic Details

Child's Name: Gunav
Age: 5 Year 10 Month 22 Days
Gender: Male
DOB: 2020-09-28
Mother’s age (years): 40 years
Mother’s occupation: Homemaker
Father’s age (years): 42 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Chetakpuri
Contact: 9410477727
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Behavioral concerns

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Inattention Temper tantrums Stubbornness Aggression

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): MAlpresentation
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: admitted on day 3 for 2 days for NNHB

Past history:

Hospitalization: No Seizures: No

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: 9 months
Walking without support: Achieved

Age of attainment: 14 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: 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: 2-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: Delayed

Complete sentences: Achieved

Age of attainment: Delayed

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: Delayed

Complete sentences: Achieved

Age of attainment: Delayed

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): 2-step

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 6 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Toilet training: 4. Needs minimal assistance
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Type of Play : 5. Associative Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Seven I
Grade: UKG
Hours spent in school: 4:30 hours

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 7 hours
Afternoon nap: No

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 27 Kg Height: 122 cm Head circumference: 52.5 cm

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

Impression: Behavioral dysregulation

Advice

Evaluation: BASC
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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