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OPD : 11-May-2026 02:36PM Demographic Details Child's Name: Gouravi Yadav Age: 10 Month 8 Days Gender: Female DOB: 2025-07-03 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 28 years Father’s occupation: Business Type of family: Joint Number of family members: 9 Number of siblings: 0 Contact: 9753938907 Referred By: Doctor Presenting Concerns Chief concerns: Delayed milestones Behavioral history: 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: 2.4 Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 15 days for birth asphyxia, respiratory distress Past history: Hospitalization: No Seizures: No Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Done Details: Normal Vision assessment: Done Details: Normal Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Roll over: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: Babbling: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Predominantly on milk Food allergies: No Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 7 Kg Height: 68 cm Head circumference: 41 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: Ab Superficial reflexes: Extensor/ extensor Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Others: No teething. Frequent choking episodes CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD with birth asphyxia Advice Intervention plan: IDP (+PT) 5/ week Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 11-May-2026 02:36PM Demographic Details

Child's Name: Gouravi Yadav
Age: 10 Month 8 Days
Gender: Female
DOB: 2025-07-03
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 28 years
Father’s occupation: Business
Type of family: Joint
Number of family members: 9
Number of siblings: 0
Contact: 9753938907
Referred By: Doctor

Presenting Concerns

Chief concerns: Delayed milestones

Behavioral history:

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: 2.4
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 15 days for birth asphyxia, respiratory distress

Past history:

Hospitalization: No Seizures: No

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

Hearing assessment: Done Details: Normal Vision assessment: Done Details: Normal

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved
Roll over: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment:

Babbling: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Predominantly on milk
Food allergies: No

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 7 Kg Height: 68 cm Head circumference: 41 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: Ab
Superficial reflexes: Extensor/ extensor

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Others: No teething. Frequent choking episodes

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

Impression: GDD with birth asphyxia

Advice

Intervention plan: IDP (+PT) 5/ week
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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