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Demographic Details Child's Name: Yuvraj Age: 1 Year 11 Month 26 Days Gender: Male DOB: 2024-02-12 Contact: 123456 Interaction history: Interaction: 80 Behavioral history: Others Emotional History Details: jnjnjl Academic Concerns: Difficulty understanding word problems Sensory Concerns: Tactile: Hyposensitive Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Roll over: Achieved Age of attainment: Sitting without support: Achieved Age of attainment: Standing without support: Achieved Age of attainment: Walking without support: Achieved Age of attainment: Fine Motor Pincer grasp: Scribbling: Not achieved Drinking from cup: Buttoning / Unbuttoning: Language Expressive:- Cooing: Babbling: Meaningful words: 2 word Phrases: Not achieved Complete sentences: Not achieved Narrates events / stories: juinuiui Expressive:- Cooing: Babbling: Meaningful words: 2 word Phrases: Not achieved Complete sentences: Not achieved Narrates events / stories: juinuiui Communication & Language Assessment Non-Verbal Communication Grading:- Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Answering Questions:- Social Social smile: Stranger anxiety: Waving bye bye: Not achieved Comes when called: Copying parents in tasks: Asking for food and toilet: Not achieved Response to Name Call Details: i Sitting tolerance- (in minutes) For interaction: bhi For tasks: bkh ADL Skills (Age-appropriate)- Type of Play : Outdoor play duration: bk Academic History: Name of School: kb Grade: khb Hours spent in school: hkb Location: bhk Additional information: bhk Diet History: Food preferences: bhk Junk food intake: bhk Calorie intake: bhkbhkb Protein intake: hkbhkbhkb Sleep History Total sleep duration (night): hkb Sleep disturbances: Examination a. Vitals: HR: hbhkbhk RR: bhkbhk Temperature: bhkbhkb BP: khbhkb b. Anthropometry: Weight: hkb Height: hb Head circumference: hk c. General Examination Dysmorphology: hb Neurocutaneous markers: hbh Others: bh d. CNS: Higher Mental Functions Consciousness: b Orientation: hbh Memory: bh Repetition: bh Naming: h Voice: b Judgement: hb Insight: hb Perception: hb Sensory Examination Touch: h Pain: bh Temperature: b 2-point discrimination: h Stereognosis: hb Graphesthesia: hb Proprioception: hb Cranial Nerves (1–12) Olfactory nerve: h Optic Nerve: bh cculomotor, Trochlear, Abducent: bh Trigeminal Nerve: j Facial Nerve: bhb Vestibulocochlear Nerve: hj Glossopharyngeal Nerve: bhj Vagus Nerve: bhjb Spinal Accessory: hb Hypoglossal Nerve: hb Neuromuscular Concerns Bulk of muscles: bhjkjnkjKJ Tone: Hypotonia Power: BH Deep tandon reflexes: HJ Gait issues: BHJ Posture issues: B Other: HBH Cerebellar examination: BH If present details: HH Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Others: UI CVS examination: U Respiratory System examination: NN Per abdomen examination: JN Impression: N Advice Intervention plan: UN Investigations: JKN Medications: JN Follow up plan: JN

Demographic Details

Child's Name: Yuvraj
Age: 1 Year 11 Month 26 Days
Gender: Male
DOB: 2024-02-12
Contact: 123456

Interaction history:

Interaction: 80

Behavioral history:

Others Emotional History Details: jnjnjl Academic Concerns:
Difficulty understanding word problems
Sensory Concerns:

Tactile: Hyposensitive
Auditory: Hypersensitive
Visual: Seeks visuals
Proprioception: Seeks pressure
Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment:
Roll over: Achieved

Age of attainment:
Sitting without support: Achieved

Age of attainment:
Standing without support: Achieved

Age of attainment:
Walking without support: Achieved

Age of attainment:

Fine Motor

Pincer grasp:

Scribbling: Not achieved

Drinking from cup:

Buttoning / Unbuttoning:

Language

Expressive:-

Cooing:

Babbling:

Meaningful words:

2 word Phrases: Not achieved

Complete sentences: Not achieved

Narrates events / stories: juinuiui

Expressive:-

Cooing:

Babbling:

Meaningful words:

2 word Phrases: Not achieved

Complete sentences: Not achieved

Narrates events / stories: juinuiui

Communication & Language Assessment

Non-Verbal Communication Grading:-

Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing

Answering Questions:-

Social

Social smile:
Stranger anxiety:
Waving bye bye: Not achieved
Comes when called:
Copying parents in tasks:
Asking for food and toilet: Not achieved

Response to Name Call

Details: i

Sitting tolerance- (in minutes)

For interaction: bhi
For tasks: bkh

ADL Skills (Age-appropriate)-

Type of Play : Outdoor play duration: bk Academic History:

Name of School: kb
Grade: khb
Hours spent in school: hkb
Location: bhk
Additional information: bhk

Diet History:

Food preferences: bhk
Junk food intake: bhk
Calorie intake: bhkbhkb
Protein intake: hkbhkbhkb

Sleep History

Total sleep duration (night): hkb
Sleep disturbances:

Examination

a. Vitals:

HR: hbhkbhk RR: bhkbhk Temperature: bhkbhkb BP: khbhkb

b. Anthropometry:

Weight: hkb Height: hb Head circumference: hk

c. General Examination

Dysmorphology: hb Neurocutaneous markers: hbh Others: bh

d. CNS: Higher Mental Functions

Consciousness: b
Orientation: hbh
Memory: bh
Repetition: bh
Naming: h
Voice: b
Judgement: hb
Insight: hb
Perception: hb

Sensory Examination

Touch: h
Pain: bh
Temperature: b
2-point discrimination: h
Stereognosis: hb
Graphesthesia: hb
Proprioception: hb

Cranial Nerves (1–12)

Olfactory nerve: h
Optic Nerve: bh
cculomotor, Trochlear, Abducent: bh
Trigeminal Nerve: j
Facial Nerve: bhb
Vestibulocochlear Nerve: hj
Glossopharyngeal Nerve: bhj
Vagus Nerve: bhjb
Spinal Accessory: hb
Hypoglossal Nerve: hb

Neuromuscular Concerns

Bulk of muscles: bhjkjnkjKJ
Tone: Hypotonia
Power: BH
Deep tandon reflexes: HJ
Gait issues: BHJ
Posture issues: B
Other: HBH

Cerebellar examination: BH

If present details: HH

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: UI

CVS examination: U
Respiratory System examination: NN
Per abdomen examination: JN

Impression: N

Advice

Intervention plan: UN
Investigations: JKN
Medications: JN
Follow up plan: JN

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