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OPD : 23-Jul-2026 12:54PM Demographic Details Child's Name: Abhishek Patel Age: 5 Year 11 Month 28 Days Gender: Male DOB: 2020-07-25 Mother’s age (years): 29 years Mother’s occupation: Homemaker Father’s age (years): 36 years Father’s occupation: Farming Type of family: Joint Number of family members: 8 Number of siblings: 0 Address: Banda Contact: 6268906805 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Sustained Interaction: Avoids due to difficulty in communication Quality of Interaction: avoids Behavioral history: Hyperactivity Inattention Impulsivity Object obsession Stubbornness Aggression Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Home Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.5 Kg Resuscitation required: No NICU stay: No If yes- Duration & Indication: ? weak cry/delayed cry Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Investigations done- Hearing assessment: Done Details: BERA- right ear- normal, Left ear- mild to moderate hearing loss 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: 18 months Walking without support: Achieved Age of attainment: 2 years 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: Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 12 months Pointing: Achieved Age of attainment: 24 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 3 years Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Narrates events / stories: No Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 3 years Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Narrates events / stories: No 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:- Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 2 years Waving bye bye: Achieved Age of attainment: 5 years Comes when called: Achieved Age of attainment: Response to Name Call Details: 5/10 Sitting tolerance- (in minutes) For interaction: Sits longer but fidgeti ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 3. Needs significant assistance Toilet training: 5. Independent Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Unable to apply soap. Type of Play : 4. Parallel Academic History: Is child enrolled in school: Yes Name of School: Anganbadi Hours spent in school: 3-4 hours Additional information: Started going to anganbadi since 7 days Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 16 Kg Height: 112 cm Head circumference: 49 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab Others: Predominantly open mouth 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 CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ID Advice Intervention plan: Home startegies adviced Evaluation: DQ, Speech and Language Evaluations Investigations: CBC, Thyroid profile, LFT, RFT, RBS, Calcium, vitamin D. MRI Brain Medications: Continue same as adviced by pediatrician Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 23-Jul-2026 12:54PM Demographic Details

Child's Name: Abhishek Patel
Age: 5 Year 11 Month 28 Days
Gender: Male
DOB: 2020-07-25
Mother’s age (years): 29 years
Mother’s occupation: Homemaker
Father’s age (years): 36 years
Father’s occupation: Farming
Type of family: Joint
Number of family members: 8
Number of siblings: 0
Address: Banda
Contact: 6268906805
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Sustained
Interaction: Avoids due to difficulty in communication
Quality of Interaction: avoids

Behavioral history:

Hyperactivity Inattention Impulsivity Object obsession Stubbornness Aggression

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Home
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.5 Kg
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: ? weak cry/delayed cry

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Investigations done-

Hearing assessment: Done Details: BERA- right ear- normal, Left ear- mild to moderate hearing loss 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: 18 months
Walking without support: Achieved

Age of attainment: 2 years
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:

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 12 months
Pointing: Achieved

Age of attainment: 24 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 3 years

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Narrates events / stories: No

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 3 years

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Narrates events / stories: No

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:-

Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 2 years
Waving bye bye: Achieved

Age of attainment: 5 years
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 5/10

Sitting tolerance- (in minutes)

For interaction: Sits longer but fidgeti

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 3. Needs significant assistance
Toilet training: 5. Independent
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Details:: Unable to apply soap.

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: Yes
Name of School: Anganbadi
Hours spent in school: 3-4 hours
Additional information: Started going to anganbadi since 7 days

Diet History:

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

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 16 Kg Height: 112 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab Others: Predominantly open mouth

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

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

Impression: ?ID

Advice

Intervention plan: Home startegies adviced
Evaluation: DQ, Speech and Language Evaluations
Investigations: CBC, Thyroid profile, LFT, RFT, RBS, Calcium, vitamin D. MRI Brain
Medications: Continue same as adviced by pediatrician
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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