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OPD : 27-Oct-2026 12:23PM Demographic Details Child's Name: Prince Soni Age: 5 Year 9 Month 22 Days Gender: Male DOB: 2021-01-05 Contact: 6268893295 Current Improvements: started involving in ADLs, HHCs Current concerns: Hyperactivity Interaction history: Eye contact: Sustained Interaction: Inappropriate Behavioral history: Repetitive behaviors (RRBs): Handfflapping, looking from corner of eyes Hyperactivity Inattention Impulsivity Stubbornness Aggression Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- 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:- Social Response to Name Call Sitting tolerance- (in minutes) For tasks: 10-15 minutes ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Toilet training: 3. Needs significant assistance Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Additional information: Going to coaching Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Impression: Unable to come for physical sessions Advice Investigations: MRI Brain. CBC, Calcium,Vitamin D, Vitamin B12, free T3, freeT4, TSH Medications: Tab Risdone 0.5 mg 1 tab at evening 8 PM. Tab Axepta 10mg 1/2 tab OD after breakfast for 15 days then 1 tab OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 27-Oct-2026 12:23PM Demographic Details

Child's Name: Prince Soni
Age: 5 Year 9 Month 22 Days
Gender: Male
DOB: 2021-01-05
Contact: 6268893295
Current Improvements: started involving in ADLs, HHCs
Current concerns: Hyperactivity

Interaction history:

Eye contact: Sustained
Interaction: Inappropriate

Behavioral history:

Repetitive behaviors (RRBs): Handfflapping, looking from corner of eyes Hyperactivity Inattention Impulsivity Stubbornness Aggression
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

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:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

For tasks: 10-15 minutes

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Toilet training: 3. Needs significant assistance
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No
Additional information: Going to coaching

Diet History:

Food preferences: Mixed
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Impression: Unable to come for physical sessions

Advice

Investigations: MRI Brain. CBC, Calcium,Vitamin D, Vitamin B12, free T3, freeT4, TSH
Medications: Tab Risdone 0.5 mg 1 tab at evening 8 PM. Tab Axepta 10mg 1/2 tab OD after breakfast for 15 days then 1 tab OD
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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