Create - Child Development Centre

Patient Details


OPD : 22-Jul-2026 10:58AM Demographic Details Child's Name: Divyanshi Rajput Age: 3 Year 6 Month 23 Days Gender: Female DOB: 2022-12-29 Mother’s age (years): 22 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Farming Type of family: Joint Number of family members: 7 Number of siblings: 0 Address: Jhansi Contact: 6394517213 Referred By: Healthcare worker Informant: Father, Grandmother Presenting Concerns Chief concerns: Speech Delay Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Sensory Concerns: Visual: Seeks visuals Proprioception: Seeks pressure Vestibular: Seeks movement Details:: Doesnt cooperate for haircut and nailcut 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: 2.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: BERA- normal 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: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 18 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: 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 Drinking from cup: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 2 years. Inconsistent Pointing: Achieved Age of attainment: 2.5 years. Inconsistent Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Cued pointing Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: Stranger anxiety: Not achieved Response to Name Call Details: 6/10 Sitting tolerance- (in minutes) For interaction: 1-2 minutes For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 12 kg Height: 90 cm Head circumference: 46 cm c. General Examination Dysmorphology: ab Neurocutaneous markers: ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+ Superficial reflexes: B/l flexors Meningeal signs: Absent Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Prefers sitting in w position CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ? ASD Advice Intervention plan: IDP 1/week + PMT 1/week Evaluation: DQ, ISAA, DSM5 ASD (Later) Medications: Syp Histafer (30mg/5ml) 4ml BD, Syp Autinorm 5ml OD Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-Jul-2026 10:58AM Demographic Details

Child's Name: Divyanshi Rajput
Age: 3 Year 6 Month 23 Days
Gender: Female
DOB: 2022-12-29
Mother’s age (years): 22 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Farming
Type of family: Joint
Number of family members: 7
Number of siblings: 0
Address: Jhansi
Contact: 6394517213
Referred By: Healthcare worker
Informant: Father, Grandmother

Presenting Concerns

Chief concerns: Speech Delay

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects
Sensory Concerns:

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

Details:: Doesnt cooperate for haircut and nailcut

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: 2.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Done Details: BERA- normal 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: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 18 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: 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

Drinking from cup: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 2 years. Inconsistent
Pointing: Achieved

Age of attainment: 2.5 years. Inconsistent
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Inconsistent
Drag for needs: Inconsistent
Joint attention: Inconsistent
Pointing: Cued pointing
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment:
Stranger anxiety: Not achieved

Response to Name Call

Details: 6/10

Sitting tolerance- (in minutes)

For interaction: 1-2 minutes
For tasks: 1-2 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

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

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 12 kg Height: 90 cm Head circumference: 46 cm

c. General Examination

Dysmorphology: ab Neurocutaneous markers: ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal
Deep tendon reflexes: KJ-2+/2+, AJ-2+/2+
Superficial reflexes: B/l flexors

Meningeal signs: Absent

Oromotor Examination

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

Examination summary: Prefers sitting in w position CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ? ASD

Advice

Intervention plan: IDP 1/week + PMT 1/week
Evaluation: DQ, ISAA, DSM5 ASD (Later)
Medications: Syp Histafer (30mg/5ml) 4ml BD, Syp Autinorm 5ml OD
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

Setting Panel

Select Layout

Light Dark

Sidebar Color

Color Theme

Mini Sidebar

Sticky Header

Patient Details print

Select Layout

Sidebar Color

Color Theme

Patient Details