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OPD : 15-Jul-2026 05:47PM Demographic Details Child's Name: Divyansh Rawat Age: 1 Year Gender: Male DOB: 2025-07-15 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 25 years Father’s occupation: Farmer Type of family: Joint Number of siblings: 0 Address: Karaira Contact: 7610646522 Referred By: Doctor Informant: Mother Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Birth Weight: 2.7 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: Leaking PV. Nicu stay- 1 month. HIE 2 Past history: Hospitalization: No Seizures: Yes Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Sitting without support: Not achieved Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Pincer 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 Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 1 year Stranger anxiety: Not achieved Waving bye bye: Not achieved 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: Is child enrolled in school: No Diet History: Food preferences: Predominantly milk Food allergies: No Sleep History Total sleep duration (night): 8 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 5.9 Kg Height: 68 cm Head circumference: 40.5 cm c. General Examination Others: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Wasting+ Tone: Hypertonia Deep tendon reflexes: KJ - 3+/3+, AJ-3+/3+ Superficial reflexes: Plantars- extensors If present details: AF- admitting finger tip Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP +PT 3/week Investigations: EEG (later) Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 15-Jul-2026 05:47PM Demographic Details

Child's Name: Divyansh Rawat
Age: 1 Year
Gender: Male
DOB: 2025-07-15
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 25 years
Father’s occupation: Farmer
Type of family: Joint
Number of siblings: 0
Address: Karaira
Contact: 7610646522
Referred By: Doctor
Informant: Mother

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Birth Weight: 2.7 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: Leaking PV. Nicu stay- 1 month. HIE 2

Past history:

Hospitalization: No Seizures: Yes

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved
Sitting without support: Not achieved
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Pincer 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
Drag for needs: Absent
Joint attention: Absent
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 1 year
Stranger anxiety: Not achieved
Waving bye bye: Not achieved

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:

Is child enrolled in school: No

Diet History:

Food preferences: Predominantly milk
Food allergies: No

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 5.9 Kg Height: 68 cm Head circumference: 40.5 cm

c. General Examination

Others: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Wasting+
Tone: Hypertonia
Deep tendon reflexes: KJ - 3+/3+, AJ-3+/3+
Superficial reflexes: Plantars- extensors

If present details: AF- admitting finger tip

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

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

Advice

Intervention plan: IDP +PT 3/week
Investigations: EEG (later)
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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