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OPD : 04-May-2026 03:03PM Demographic Details Child's Name: Madhav Yadav Age: 3 Year 4 Month 9 Days Gender: Male DOB: 2022-12-25 Mother’s age (years): 30 years Mother’s occupation: Homemaker Father’s age (years): 37 years Father’s occupation: Govt job Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 7 year old female Address: Badagaon Contact: 7898897842 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Clarity of speech Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Temper tantrums Stubbornness Aggression 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: 2.9 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: OAE- pass 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: 9 months Walking without support: Achieved Age of attainment: 12 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: Achieved Age of attainment: Standing on one foot: Achieved Age of attainment: Skipping: 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 Language Receptive:- Joint attention: Achieved Age of attainment: 8 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4months Babbling: Achieved Age of attainment: 7 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 2 years Expressive:- Cooing: Achieved Age of attainment: 4months Babbling: Achieved Age of attainment: 7 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Achieved Age of attainment: 2 years Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Consistent Following commands (gesture + verbal): 1-step Answering Questions:- What Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 1 minutes For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 5. Associative Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Jaipuria Grade: Nursery Hours spent in school: 4.5 hours Location: City centre Diet History: Food preferences: Mixed (doesnt est fruit) Food allergies: No Junk food intake: Once in a month Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: > 5 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 13 Kg Height: 95 cm Head circumference: 51 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAd d. CNS: Higher Mental Functions Consciousness: Conscious Orientation: Oriented to place and person Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Misarticulation+, nasal twang CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 1/week + PMT 1/week Evaluation: Speech evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 04-May-2026 03:03PM Demographic Details

Child's Name: Madhav Yadav
Age: 3 Year 4 Month 9 Days
Gender: Male
DOB: 2022-12-25
Mother’s age (years): 30 years
Mother’s occupation: Homemaker
Father’s age (years): 37 years
Father’s occupation: Govt job
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 7 year old female
Address: Badagaon
Contact: 7898897842
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Clarity of speech

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Temper tantrums Stubbornness Aggression

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

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: OAE- pass 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: 9 months
Walking without support: Achieved

Age of attainment: 12 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: Achieved

Age of attainment:
Standing on one foot: Achieved

Age of attainment:
Skipping: 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

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 8 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4months

Babbling: Achieved

Age of attainment: 7 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 2 years

Expressive:-

Cooing: Achieved

Age of attainment: 4months

Babbling: Achieved

Age of attainment: 7 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Achieved

Age of attainment: 2 years

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

What

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

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

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 5. Associative Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Jaipuria
Grade: Nursery
Hours spent in school: 4.5 hours
Location: City centre

Diet History:

Food preferences: Mixed (doesnt est fruit)
Food allergies: No
Junk food intake: Once in a month

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

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

Examination

a. Vitals:

b. Anthropometry:

Weight: 13 Kg Height: 95 cm Head circumference: 51 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAd

d. CNS: Higher Mental Functions

Consciousness: Conscious
Orientation: Oriented to place and person

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Examination summary: Misarticulation+, nasal twang CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: IDP 1/week + PMT 1/week
Evaluation: Speech evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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