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OPD : 02-Oct-2026 02:27PM Demographic Details Child's Name: Harsh Thapak Age: 10 Year 8 Month 8 Days Gender: Male DOB: 2016-01-24 Mother’s age (years): 36 years Father’s age (years): 43 years Father’s occupation: Teacher Type of family: Nuclear Number of family members: 3 Number of siblings: 1 Address: Parents Contact: 9669689010 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Doesnt express his thoughts, Academic concerns, low self confidence, doesnt make friends Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Inattention Stubbornness Academic Concerns: Poor scholastic performance Poor recall of learnt material Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Oligohydramnios Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress, cord around neck Gestational Age: 32 weeks Birth Weight: 1.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: Admitted for NNHB on day 2 of life. Neonatal seziures noted. AED given for 3 years Past history: Hospitalization: Yes Seizures: Yes Others: At 4 years age- febrile seizures. Admitted for 1 day. Discharged on AED. no seizures after that Past/Current therapies: Nil Past/Current medications: Valprol, Levera 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: Running: Achieved Age of attainment: Climbing upstairs: 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: 3-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: Complete sentences: 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: 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): 3-step Answering Questions:- 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 Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Details:: Eats with mobile Type of Play : 5. Associative Details:: understand simple games Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Gurukulam Grade: 5 Hours spent in school: 7 hours Board: CBSE Location: Sithouli road Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 7 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“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 Advice Intervention plan: IQ evaluation Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-Oct-2026 02:27PM Demographic Details

Child's Name: Harsh Thapak
Age: 10 Year 8 Month 8 Days
Gender: Male
DOB: 2016-01-24
Mother’s age (years): 36 years
Father’s age (years): 43 years
Father’s occupation: Teacher
Type of family: Nuclear
Number of family members: 3
Number of siblings: 1
Address: Parents
Contact: 9669689010
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Doesnt express his thoughts, Academic concerns, low self confidence, doesnt make friends

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Inattention Stubbornness Academic Concerns:
Poor scholastic performance Poor recall of learnt material

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
2. Oligohydramnios

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress, cord around neck
Gestational Age: 32 weeks
Birth Weight: 1.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: Admitted for NNHB on day 2 of life. Neonatal seziures noted. AED given for 3 years

Past history:

Hospitalization: Yes Seizures: Yes Others: At 4 years age- febrile seizures. Admitted for 1 day. Discharged on AED. no seizures after that

Past/Current therapies: Nil Past/Current medications: Valprol, Levera 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:
Running: Achieved

Age of attainment:
Climbing upstairs: 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: 3-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:

Complete sentences: 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:

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): 3-step

Answering Questions:-

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

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Details:: Eats with mobile

Type of Play : 5. Associative Details:: understand simple games Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Gurukulam
Grade: 5
Hours spent in school: 7 hours
Board: CBSE
Location: Sithouli road

Diet History:

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

Sleep History

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

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“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

Advice

Intervention plan: IQ evaluation
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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