Create - Child Development Centre

Patient Details


OPD : 29-Apr-2026 01:49PM Demographic Details Child's Name: Yuvraj Gurjar Age: 2 Year 7 Month 3 Days Gender: Male DOB: 2023-09-26 Mother’s age (years): 22 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: ICICI Type of family: Nuclear Number of family members: 3 Address: Tekanpur Contact: 9243116415 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, Behavioral concerns Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): CPD Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No Past history: Hospitalization: No Seizures: No Others: Recurrent cough and cold, vomiting Past/Current therapies: Nil Past/Current medications: nil Investigations done- Hearing assessment: Done Details: Reports not there Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3 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: 9 months Walking without support: Achieved Age of attainment: 12 months 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: 1 to 2 minutes For tasks: 1 to 2 minutes Details:: Response to name call and sitting tolerance better with mother ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Doesnt cooperate for haircut, nailcut Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater . Bottlefeeding Food allergies: No Junk food intake: Zero Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD. M chat R score- 14 Advice Intervention plan: IDP 2/week +PMT 1/week Evaluation: ISAA, DSM5 ASD (Later) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 29-Apr-2026 01:49PM Demographic Details

Child's Name: Yuvraj Gurjar
Age: 2 Year 7 Month 3 Days
Gender: Male
DOB: 2023-09-26
Mother’s age (years): 22 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: ICICI
Type of family: Nuclear
Number of family members: 3
Address: Tekanpur
Contact: 9243116415
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, Behavioral concerns

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): CPD
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No

Past history:

Hospitalization: No Seizures: No Others: Recurrent cough and cold, vomiting

Past/Current therapies: Nil Past/Current medications: nil Investigations done-

Hearing assessment: Done Details: Reports not there Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3 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: 9 months
Walking without support: Achieved

Age of attainment: 12 months

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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: 1 to 2 minutes
For tasks: 1 to 2 minutes

Details:: Response to name call and sitting tolerance better with mother

ADL Skills (Age-appropriate)-

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

Details:: Doesnt cooperate for haircut, nailcut

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater . Bottlefeeding
Food allergies: No
Junk food intake: Zero

Sleep History

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

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: ? ASD. M chat R score- 14

Advice

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

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details