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OPD : 04-May-2026 12:53PM Demographic Details Child's Name: Shivansh Singh Tomar Age: 2 Year 3 Month 2 Days Gender: Male DOB: 2024-02-02 Mother’s age (years): 29 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: IT (Work from home) Type of family: Joint Number of family members: 5 Number of siblings: 6 Address: Adarshpuram Contact: 9806709042 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, poor response to name call Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): running to and fro, toe walking Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Sensory Concerns: Auditory: Hypersensitive Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Bicornuate uterus, cord around neck Gestational Age: 36 weeks Birth Weight: 2.6 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for 5 days for RDS (on CPAP) Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Done Details: Normal. Reports not brought 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: 7 months Sitting without support: Achieved Age of attainment: 8 months Standing without support: Walking without support: Achieved Age of attainment: 16 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 Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 1 year Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 1 year Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: 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: 9 months Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 1-2 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Outdoor play duration: 1 hour Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed diet. Bottlefeeding 3-4 times Food allergies: No Junk food intake: Biscuits occasionally Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper Examination summary: Mild hypotonia CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: M chat r score- 16 (High risk) Advice Intervention plan: IDP 2/week +PMT 1/week Follow up plan: after 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 04-May-2026 12:53PM Demographic Details

Child's Name: Shivansh Singh Tomar
Age: 2 Year 3 Month 2 Days
Gender: Male
DOB: 2024-02-02
Mother’s age (years): 29 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: IT (Work from home)
Type of family: Joint
Number of family members: 5
Number of siblings: 6
Address: Adarshpuram
Contact: 9806709042
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, poor response to name call

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): running to and fro, toe walking Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression
Sensory Concerns:

Auditory: Hypersensitive
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Bicornuate uterus, cord around neck
Gestational Age: 36 weeks
Birth Weight: 2.6 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for 5 days for RDS (on CPAP)

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Done Details: Normal. Reports not brought 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: 7 months
Sitting without support: Achieved

Age of attainment: 8 months
Standing without support:
Walking without support: Achieved

Age of attainment: 16 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

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 1 year

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 1 year

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: 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: 9 months

Response to Name Call

Sitting tolerance- (in minutes)

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

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: 1 hour Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed diet. Bottlefeeding 3-4 times
Food allergies: No
Junk food intake: Biscuits occasionally

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Examination summary: Mild hypotonia CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: M chat r score- 16 (High risk)

Advice

Intervention plan: IDP 2/week +PMT 1/week
Follow up plan: after 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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