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OPD : 22-Jun-2026 10:25AM Demographic Details Child's Name: Parth Jadon Age: 2 Year 5 Month 19 Days Gender: Male DOB: 2024-01-03 Mother’s age (years): 27 years Mother’s occupation: Homemaker Father’s age (years): 30 years Father’s occupation: Business Type of family: Nuclear Number of siblings: 1 Details of siblings (Age and sex): 3.5 year old female Address: Joura Contact: 8516026921 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, poor interaction Interaction history: Eye contact: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, spinning, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing Sensory Concerns: Tactile: Hypersensitive Auditory: Hyposensitive Visual: Seeks visuals 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): Previous LSCS Gestational Age: FT Birth Weight: Not known Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: Repeated cough cold 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: 7 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: 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: Achieved Age of attainment: Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Not achieved 2 word Phrases: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Drag for needs: Absent Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Not achieved Waving bye bye: Not achieved Comes when called: Not achieved Copying parents in tasks: Not achieved Asking for food and toilet: Not achieved 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 Details:: Doesnt cooperate for haircut and nailcut Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater. Bottlefeeding+ Food allergies: No Junk food intake: Frequent Sleep History Total sleep duration (night): 11-12 hours Afternoon nap: Yes Duration of Afternoon nap: 2-3 hours Sleep disturbances: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Increased hair growth over body, Mild xerosis, no scaling d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tendon reflexes: KJ-2+/2+, AJ-2+,2+ Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper Examination summary: Mild hypotonia. Sits in W position. 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 Investigations: WES (Later) Follow up plan: every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-Jun-2026 10:25AM Demographic Details

Child's Name: Parth Jadon
Age: 2 Year 5 Month 19 Days
Gender: Male
DOB: 2024-01-03
Mother’s age (years): 27 years
Mother’s occupation: Homemaker
Father’s age (years): 30 years
Father’s occupation: Business
Type of family: Nuclear
Number of siblings: 1
Details of siblings (Age and sex): 3.5 year old female
Address: Joura
Contact: 8516026921
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, poor interaction

Interaction history:

Eye contact: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, spinning, stimming Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Mouthing of objects Others Emotional History Details: Irrelevant laughing
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hyposensitive
Visual: Seeks visuals
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): Previous LSCS
Gestational Age: FT
Birth Weight: Not known
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: Repeated cough cold

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: 7 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:

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: Achieved

Age of attainment:

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Not achieved
Waving bye bye: Not achieved
Comes when called: Not achieved
Copying parents in tasks: Not achieved
Asking for food and toilet: Not achieved

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

Details:: Doesnt cooperate for haircut and nailcut

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater. Bottlefeeding+
Food allergies: No
Junk food intake: Frequent

Sleep History

Total sleep duration (night): 11-12 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2-3 hours
Sleep disturbances: No

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Increased hair growth over body, Mild xerosis, no scaling

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tendon reflexes: KJ-2+/2+, AJ-2+,2+

Oromotor Examination

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

Examination summary: Mild hypotonia. Sits in W position. 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
Investigations: WES (Later)
Follow up plan: every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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