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OPD : 12-May-2026 03:00PM Demographic Details Child's Name: Naina Saxena Age: 11 Month 3 Days Gender: Female DOB: 2025-06-09 Mother’s age (years): 46 years Mother’s occupation: Teacher Father’s age (years): 50 years Father’s occupation: Private job Type of family: Nuclear Number of family members: 3 Number of siblings: 0 Address: Vinay year Contact: 9827336861 Referred By: Doctor Interaction history: Eye contact: Sustained Behavioral history: Birth & Perinatal History: Antenatal History Others:: Adopted child (adopted at day 2 of life) Natal and Postnatal History: If yes- Duration & Indication: Not available Past history: Hospitalization: No Seizures: No Others: H/o Measles at 5 months Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Done Family history: Neuropsychiatric condition: No Details (If yes): Not known Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 9 months Sitting without support: Not achieved Standing without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months Babbling: Not achieved Expressive:- Cooing: Achieved Age of attainment: 6 months 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 : 2. Isolated Academic History: Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): as per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 8 Kg Height: 69 cm Head circumference: 40.5 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor Tone: Normal Deep tendon reflexes: KJ-3+/3+ Superficial reflexes: Plantars- B/l flexors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: IDP 2/week Investigations: MRI Brain + MR spectroscopy Follow up plan: Review after MRI Brain General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 12-May-2026 03:00PM Demographic Details

Child's Name: Naina Saxena
Age: 11 Month 3 Days
Gender: Female
DOB: 2025-06-09
Mother’s age (years): 46 years
Mother’s occupation: Teacher
Father’s age (years): 50 years
Father’s occupation: Private job
Type of family: Nuclear
Number of family members: 3
Number of siblings: 0
Address: Vinay year
Contact: 9827336861
Referred By: Doctor

Interaction history:

Eye contact: Sustained

Behavioral history:

Birth & Perinatal History: Antenatal History

Others:: Adopted child (adopted at day 2 of life)

Natal and Postnatal History:

If yes- Duration & Indication: Not available

Past history:

Hospitalization: No Seizures: No Others: H/o Measles at 5 months

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

Hearing assessment: Not done Vision assessment: Done

Family history:

Neuropsychiatric condition: No Details (If yes): Not known

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 9 months
Sitting without support: Not achieved
Standing without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

Babbling: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 6 months

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 : 2. Isolated Academic History:

Diet History:

Food preferences: Mixed diet
Food allergies: No
Junk food intake: Nil

Sleep History

Total sleep duration (night): as per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 8 Kg Height: 69 cm Head circumference: 40.5 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor
Tone: Normal
Deep tendon reflexes: KJ-3+/3+
Superficial reflexes: Plantars- B/l flexors

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

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

Impression: GDD

Advice

Intervention plan: IDP 2/week
Investigations: MRI Brain + MR spectroscopy
Follow up plan: Review after MRI Brain
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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