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Patient Details


OPD : 08-Sep-2026 05:09PM Demographic Details Child's Name: Animesh Age: 9 Year 10 Month 2 Days Gender: Male DOB: 2016-11-05 Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 6-year-old male Address: Govindpuri Contact: 7049235989 Informant: Parents Current medications: Nil Presenting Concerns Chief concerns: Academic concerns Strengths of child: Social interaction Interaction history: Eye contact: Sustained Interaction: Avoids playing with peers Quality of Interaction: age-appropriate Behavioral history: Inattention Academic Concerns: Poor scholastic performance Difficulty in writing Incomplete notebooks Difficulty copying from the board Inattention in classroom Frequent spelling mistakes Illegible handwriting Oral better than written Difficulty understanding word problems Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FTA Birth Weight: 4.2 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Not done Details: Wearing glasses Family history: Neuropsychiatric condition: No Developmental History: Gross Motor 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: 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: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: Babbling: Achieved Age of attainment: Meaningful words: Achieved Age of attainment: 2 word Phrases: Achieved Age of attainment: Complete sentences: Achieved Age of attainment: 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 Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Type of Play : 5. Associative Details:: But avoids playing with peers. Fear of losing+. Prefers playing non competitive games. Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Rishikul Grade: 4 Hours spent in school: 5 Board: CBSE Location: Govindpuri Any change of school: No Repetition of grade: No Diet History: Food preferences: Mixed Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? SLD Advice Evaluation: IQ, DSM5 ADHD, SLD battery Follow up plan: After evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Sep-2026 05:09PM Demographic Details

Child's Name: Animesh
Age: 9 Year 10 Month 2 Days
Gender: Male
DOB: 2016-11-05
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 6-year-old male
Address: Govindpuri
Contact: 7049235989
Informant: Parents
Current medications: Nil

Presenting Concerns

Chief concerns: Academic concerns

Strengths of child: Social interaction

Interaction history:

Eye contact: Sustained
Interaction: Avoids playing with peers
Quality of Interaction: age-appropriate

Behavioral history:

Inattention Academic Concerns:
Poor scholastic performance Difficulty in writing Incomplete notebooks Difficulty copying from the board Inattention in classroom Frequent spelling mistakes Illegible handwriting Oral better than written Difficulty understanding word problems

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FTA
Birth Weight: 4.2 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Not done Details: Wearing glasses

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

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:

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:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Achieved

Age of attainment:

Meaningful words: Achieved

Age of attainment:

2 word Phrases: Achieved

Age of attainment:

Complete sentences: Achieved

Age of attainment:

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

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Type of Play : 5. Associative Details:: But avoids playing with peers. Fear of losing+. Prefers playing non competitive games. Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Rishikul
Grade: 4
Hours spent in school: 5
Board: CBSE
Location: Govindpuri
Any change of school: No
Repetition of grade: No

Diet History:

Food preferences: Mixed
Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: ? SLD

Advice

Evaluation: IQ, DSM5 ADHD, SLD battery
Follow up plan: After evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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