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OPD : 17-Jul-2026 02:04PM Demographic Details Child's Name: Vinayak singh Tomar Age: 3 Year 7 Month 18 Days Gender: Male DOB: 2022-11-29 Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 6 year female Address: Ambah Contact: 8959756910 Referred By: Relative Informant: Parents Presenting Concerns Chief concerns: Speech delay Strengths of child: Interaction is good Interaction history: Eye contact: Suboptimal Interaction: Wants to approach children Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Defiance Temper tantrums Stubbornness Sensory Concerns: Visual: Seeks visuals Proprioception: Seeks pressure Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Others:: H/o 2 spontaneous abortions at 12 weeks Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: Late PT Birth Weight: 2.150 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No If yes- Duration & Indication: Cleft lip and cleft palate Past history: Hospitalization: Yes Seizures: No Others: O/C/O- Lt side complete cleft palate with alveolar cleft. Revision surgery 3 months abck Past/Current therapies: Nil 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: 5 months Sitting without support: Achieved Age of attainment: 6 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: Climbing downstairs: Not achieved 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: Not achieved Drinking from cup: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: Meaningful words: Not achieved Details:: started speaking Mama 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:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 months Waving bye bye: Achieved Age of attainment: 12 months Comes when called: Achieved Age of attainment: Response to Name Call Details: 7/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 10-15 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 4. Needs minimal assistance Undressing: 4. Needs minimal assistance Type of Play : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Bottlefeeding. Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 -3 hours Daily Screen Time Duration: < 2 hours Examination a. Vitals: b. Anthropometry: Weight: 15 Kg Height: 75 cm Head circumference: 45 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Language and speech delay Advice Evaluation: Language and speech therapy Medications: Syp cos 3 5ml OD Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

OPD : 17-Jul-2026 02:04PM Demographic Details

Child's Name: Vinayak singh Tomar
Age: 3 Year 7 Month 18 Days
Gender: Male
DOB: 2022-11-29
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 6 year female
Address: Ambah
Contact: 8959756910
Referred By: Relative
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Strengths of child: Interaction is good

Interaction history:

Eye contact: Suboptimal
Interaction: Wants to approach children

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Hyperactivity Inattention Impulsivity Defiance Temper tantrums Stubbornness
Sensory Concerns:

Visual: Seeks visuals
Proprioception: Seeks pressure

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
Others:: H/o 2 spontaneous abortions at 12 weeks

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: Late PT
Birth Weight: 2.150 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No
If yes- Duration & Indication: Cleft lip and cleft palate

Past history:

Hospitalization: Yes Seizures: No Others: O/C/O- Lt side complete cleft palate with alveolar cleft. Revision surgery 3 months abck

Past/Current therapies: Nil 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: 5 months
Sitting without support: Achieved

Age of attainment: 6 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:
Climbing downstairs: Not achieved

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: Not achieved

Drinking from cup: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment:

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment:

Meaningful words: Not achieved

Details:: started speaking Mama

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:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 months
Waving bye bye: Achieved

Age of attainment: 12 months
Comes when called: Achieved

Age of attainment:

Response to Name Call

Details: 7/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 10-15 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 4. Needs minimal assistance
Undressing: 4. Needs minimal assistance

Type of Play : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 -3 hours

Daily Screen Time

Duration: < 2 hours

Examination

a. Vitals:

b. Anthropometry:

Weight: 15 Kg Height: 75 cm Head circumference: 45 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

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

Impression: Language and speech delay

Advice

Evaluation: Language and speech therapy
Medications: Syp cos 3 5ml OD
Follow up plan: Next 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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