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Patient Details


OPD : 15-Jul-2026 05:14PM Demographic Details Child's Name: Shivansh Singh Age: 2 Year 5 Month 6 Days Gender: Male DOB: 2024-02-09 Contact: 8878088678 Presenting Concerns Chief concerns: speech delay Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Stubbornness Sensory Concerns: Tactile: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: Gestational hypothyroidism Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: FT Birth Weight: 2.5 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: 8 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 15 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: 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 Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2.5 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2.5 years Meaningful words: Not achieved Details:: Had started saying dede, lele Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: 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: 15 months Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: better for tasks ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Details:: Difficulty with spoons Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Bottlefeeding+ Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hour Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 11 Kg c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Advice Intervention plan: IDP 2/week + PMT/week Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Jul-2026 05:14PM Demographic Details

Child's Name: Shivansh Singh
Age: 2 Year 5 Month 6 Days
Gender: Male
DOB: 2024-02-09
Contact: 8878088678

Presenting Concerns

Chief concerns: speech delay

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Stubbornness
Sensory Concerns:

Tactile: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: Gestational hypothyroidism

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: FT
Birth Weight: 2.5 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: 8 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 15 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: 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
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2.5 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2.5 years

Meaningful words: Not achieved

Details:: Had started saying dede, lele

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: 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: 15 months
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: better for tasks

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Details:: Difficulty with spoons

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed. Bottlefeeding+
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hour

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Advice

Intervention plan: IDP 2/week + PMT/week
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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