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Patient Details


Demographic Details Child's Name: Anaija Shah Age: 3 years 11 months Gender: Female DOB: 2022-04-10 Contact: 8871177040 Interaction history: Eye contact: Suboptimal Behavioral history: Mouthing of objects Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- Details:: Neck holding- improved, Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Picky eater Food allergies: No Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 9 Kg Height: 85 cm Head circumference: 48.5 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Improvement in motor milestones, stubborness reduced, understanding improved Advice Intervention plan: IDP (+PT) 3/week + PMT 1/15 days General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: Anaija Shah
Age: 3 years 11 months
Gender: Female
DOB: 2022-04-10
Contact: 8871177040

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Mouthing of objects

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

Details:: Neck holding- improved,

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Academic History:

Diet History:

Food preferences: Picky eater
Food allergies: No

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 9 Kg Height: 85 cm Head circumference: 48.5 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper

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

Impression: Improvement in motor milestones, stubborness reduced, understanding improved

Advice

Intervention plan: IDP (+PT) 3/week + PMT 1/15 days
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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