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OPD : 05-May-2026 05:14PM Demographic Details Child's Name: Raksha Age: 9 Month 27 Days Gender: Female DOB: 2025-07-08 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Business Type of family: Joint Number of family members: 5 Number of siblings: 1 Details of siblings (Age and sex): 4 year old male Address: Jalon Contact: 9974197165 Referred By: Doctor Informant: Mother, uncle Interaction history: Eye contact: Sustained Behavioral history: Sensory Concerns: Auditory: Hypersensitive Details:: Startles to sound Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: 1 sibling death at 1.5 mon age (1st child) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 3.4 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: 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: Partial Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 5 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 5 months Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 8 months Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Breastfeeding. Complimentary feed not started Food allergies: No Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 6.4 Kg (less than 3rd centile) Height: 89cm ( Head circumference: 39cm (less than 3rd centile) c. General Examination Dysmorphology: NAD Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ 3+/3+, AJ 2+/2+ Superficial reflexes: Plantar -B/l extensors If present details: AF admitting fingertip. Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Examination summary: Teething not started. Pull to sit- uplifts head. Prone- head lifted by 45degree. Hypertonia UL>LL. Long eyelashes CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: Home plan (NDT+ dietary plan) Medications: As adviced by pediatrician Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 05-May-2026 05:14PM Demographic Details

Child's Name: Raksha
Age: 9 Month 27 Days
Gender: Female
DOB: 2025-07-08
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 5
Number of siblings: 1
Details of siblings (Age and sex): 4 year old male
Address: Jalon
Contact: 9974197165
Referred By: Doctor
Informant: Mother, uncle

Interaction history:

Eye contact: Sustained

Behavioral history:

Sensory Concerns:

Auditory: Hypersensitive

Details:: Startles to sound

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: 1 sibling death at 1.5 mon age (1st child)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 3.4 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: 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: Partial
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 5 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 5 months

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 8 months

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Breastfeeding. Complimentary feed not started
Food allergies: No

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 6.4 Kg (less than 3rd centile) Height: 89cm ( Head circumference: 39cm (less than 3rd centile)

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ 3+/3+, AJ 2+/2+
Superficial reflexes: Plantar -B/l extensors

If present details: AF admitting fingertip.

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper

Examination summary: Teething not started. Pull to sit- uplifts head. Prone- head lifted by 45degree. Hypertonia UL>LL. Long eyelashes CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: GDD

Advice

Intervention plan: Home plan (NDT+ dietary plan)
Medications: As adviced by pediatrician
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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