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OPD : 10-Jul-2026 02:27PM Demographic Details Child's Name: Harsh Singh Sengar Age: 3 Year 10 Month 17 Days Gender: Male DOB: 2022-08-23 Mother’s age (years): 31 years Mother’s occupation: homemaker Father’s age (years): 32 years Father’s occupation: Service Type of family: Nuclear Number of family members: 3 Address: Morar Contact: 9682547297 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Running to and fro, jumping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: IVF Others:: Conceived after 9 years of marriage Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): MSL Gestational Age: Late PT Birth Weight: 2.9 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 3 days for MAS, after discharge readmitted for 3 days for NNHB Past history: Hospitalization: Yes Seizures: Yes Others: At 8 months- ? febrile seizures; Recurrent fever, cough cold Past/Current medications: 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: 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: 12 months Walking without support: Achieved Age of attainment: 14 months Running: Achieved Age of attainment: Climbing upstairs: 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: Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 18 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: Details:: Patterned speech Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Response to Name Call Details: 8/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 3- 5 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Doesnt indicate for urine and stool Type of Play : 4. Parallel Details:: approaches children to play Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 10 hours Afternoon nap: No Duration of Afternoon nap: Occasional Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 16.55 Kg Height: 101 cm Head circumference: 49 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: ab 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 Advice Intervention plan: IDP 2/week + PMT 1/week Evaluation: DQ, ISAA, DSM5 ADHD Medications: Syp IQ norm DHA 5 ml OD Follow up plan: after 1 month General recommendation- Zero Screen Time

OPD : 10-Jul-2026 02:27PM Demographic Details

Child's Name: Harsh Singh Sengar
Age: 3 Year 10 Month 17 Days
Gender: Male
DOB: 2022-08-23
Mother’s age (years): 31 years
Mother’s occupation: homemaker
Father’s age (years): 32 years
Father’s occupation: Service
Type of family: Nuclear
Number of family members: 3
Address: Morar
Contact: 9682547297
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Running to and fro, jumping Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

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

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: IVF
Others:: Conceived after 9 years of marriage

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): MSL
Gestational Age: Late PT
Birth Weight: 2.9 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 3 days for MAS, after discharge readmitted for 3 days for NNHB

Past history:

Hospitalization: Yes Seizures: Yes Others: At 8 months- ? febrile seizures; Recurrent fever, cough cold

Past/Current medications: 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: 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: 12 months
Walking without support: Achieved

Age of attainment: 14 months
Running: Achieved

Age of attainment:
Climbing upstairs: 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:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 18 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment:

Details:: Patterned speech

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 8/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 3- 5 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Details:: Doesnt indicate for urine and stool

Type of Play : 4. Parallel Details:: approaches children to play Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 16.55 Kg Height: 101 cm Head circumference: 49 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: ab

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

Advice

Intervention plan: IDP 2/week + PMT 1/week
Evaluation: DQ, ISAA, DSM5 ADHD
Medications: Syp IQ norm DHA 5 ml OD
Follow up plan: after 1 month
General recommendation-
1. Zero Screen Time

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