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OPD : 01-Jul-2026 02:57PM Demographic Details Child's Name: Ursiya Khan Age: 4 Year 7 Month 14 Days Gender: Female DOB: 2021-11-17 Mother’s age (years): 30 years Mother’s occupation: homemaker Father’s age (years): 35 years Father’s occupation: shop Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Karaira, Shivpuri Contact: 9074180020 Referred By: Doctor Informant: Parents Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 3 Type of conception: Natural Others:: H/o miscarriages- 4 times (7month, 3 month, 5 month, 3 month). Conceived after infertility treatment Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: Not known Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: UTI at 1 year age. AEDs given for 2 years for paroxysmal events. Past/Current therapies: Nil Investigations done- Family history: Neuropsychiatric condition: Yes Others: Some behavioral issues in distant relative Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Achieved Age of attainment: 2.4 years Walking without support: Achieved Age of attainment: 2.5 years Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: 4.5 years Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 12 months Pincer grasp: Achieved Age of attainment: Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: 4 years Buttoning / Unbuttoning: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Achieved Age of attainment: 2.5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 2 years Meaningful words: Achieved Age of attainment: 2.5 years Details:: Kinship words and few common objects Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging 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: 8 months Waving bye bye: Achieved Age of attainment: 2.5 years Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Toilet training: 4. Needs minimal assistance Dressing: 3. Needs significant assistance Undressing: 4. Needs minimal assistance Details:: Understands front and back of cloth Type of Play : 4. Parallel Details:: Doesnt understands rules of games Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Frequently Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: <30 minutes Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Height: 96 cm Head circumference: 48 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Consciousness: Conscious, playful Orientation: Oriented to persons Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: After evaluation Evaluation: VSMS, DST General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 01-Jul-2026 02:57PM Demographic Details

Child's Name: Ursiya Khan
Age: 4 Year 7 Month 14 Days
Gender: Female
DOB: 2021-11-17
Mother’s age (years): 30 years
Mother’s occupation: homemaker
Father’s age (years): 35 years
Father’s occupation: shop
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Karaira, Shivpuri
Contact: 9074180020
Referred By: Doctor
Informant: Parents

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 3
Type of conception: Natural
Others:: H/o miscarriages- 4 times (7month, 3 month, 5 month, 3 month). Conceived after infertility treatment

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: UTI at 1 year age. AEDs given for 2 years for paroxysmal events.

Past/Current therapies: Nil Investigations done-

Family history:

Neuropsychiatric condition: Yes Others: Some behavioral issues in distant relative

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support: Achieved

Age of attainment: 2.4 years
Walking without support: Achieved

Age of attainment: 2.5 years
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment: 4.5 years

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 12 months

Pincer grasp: Achieved

Age of attainment:

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment: 4 years

Buttoning / Unbuttoning: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Achieved

Age of attainment: 2.5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 2 years

Meaningful words: Achieved

Age of attainment: 2.5 years

Details:: Kinship words and few common objects

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Consistent meaningful pointing
Understanding gestures: Emerging
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: 8 months
Waving bye bye: Achieved

Age of attainment: 2.5 years
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Toilet training: 4. Needs minimal assistance
Dressing: 3. Needs significant assistance
Undressing: 4. Needs minimal assistance

Details:: Understands front and back of cloth

Type of Play : 4. Parallel Details:: Doesnt understands rules of games Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: <30 minutes
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Height: 96 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Consciousness: Conscious, playful
Orientation: Oriented to persons

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Improper

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

Impression: GDD

Advice

Intervention plan: After evaluation
Evaluation: VSMS, DST
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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