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OPD : 19-Aug-2026 05:07PM Demographic Details Child's Name: Pragnya Singh Age: 4 Year 4 Month 3 Days Gender: Male DOB: 2022-04-16 Mother’s age (years): 34 years Mother’s occupation: Enterprenur Father’s age (years): 36 years Father’s occupation: Enterprenur Type of family: Joint Number of family members: 5 Number of siblings: 0 Address: Gwalior Contact: 8800723643 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Hyperactivity, attention, doesnt write Interaction history: Eye contact: Fleeting Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Looking from corner of eyes Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness Sensory Concerns: Tactile: Hypersensitive Auditory: Fear of loud sounds Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Others:: Gestational hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: 4.2 kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil 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: 7 months Standing without support: Achieved Age of attainment: 12 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: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 12 months Details:: Patterned speech Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Inconsistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 12 months Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: Better for tasks ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 2. Started attempting Toilet training: 4. Needs minimal assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Halo Kids Grade: LKG Hours spent in school: 5 hours Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2-2.5 hours Daily Screen Time Duration: < 1 hour Type of screen: TV Examination a. Vitals: b. Anthropometry: 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 Advice Intervention plan: IDP 2/week + PMT 1/week Evaluation: ISAA, DSM 5 ASD, DSM5 ADHD Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 19-Aug-2026 05:07PM Demographic Details

Child's Name: Pragnya Singh
Age: 4 Year 4 Month 3 Days
Gender: Male
DOB: 2022-04-16
Mother’s age (years): 34 years
Mother’s occupation: Enterprenur
Father’s age (years): 36 years
Father’s occupation: Enterprenur
Type of family: Joint
Number of family members: 5
Number of siblings: 0
Address: Gwalior
Contact: 8800723643
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Hyperactivity, attention, doesnt write

Interaction history:

Eye contact: Fleeting
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Looking from corner of eyes Patterned behavior or activities: Hyperactivity Inattention Impulsivity Insisting on sameness Object obsession Temper tantrums Stubbornness
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Fear of loud sounds
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Others:: Gestational hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: 4.2 kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil 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: 7 months
Standing without support: Achieved

Age of attainment: 12 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:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 12 months

Details:: Patterned speech

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Inconsistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 12 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: Better for tasks

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Halo Kids
Grade: LKG
Hours spent in school: 5 hours

Diet History:

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

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-2.5 hours

Daily Screen Time

Duration: < 1 hour
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
Evaluation: ISAA, DSM 5 ASD, DSM5 ADHD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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