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OPD : 20-May-2026 11:15AM Demographic Details Child's Name: Pragyan Prajapati Age: 2 Year Gender: Male DOB: 2024-04-21 Mother’s age (years): 37 years Mother’s occupation: Ophthalmologist Father’s age (years): 41 years Father’s occupation: government job (PWD) Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 7.5 year male Contact: 9617139133 Referred By: Doctor Informant: Thatipur Presenting Concerns Chief concerns: Speech delay Strengths of child: Eye contact is good Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): Patterned behavior or activities: Temper tantrums Sensory Concerns: Details:: Cooperates for haircut and nailcut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Hypothyroidism Oligohydramnios Others:: Uterine adhesions. H/o ear infections Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Prev LSCS Gestational Age: 36 weeks Birth Weight: 2.6 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Admitted for NNHB (Under Phototherapy)- 5 days. Thyroid screening- normal Past history: Hospitalization: No Seizures: No Others: Anemia Past/Current therapies: Nil Past/Current medications: syp Iron Investigations done- Hearing assessment: Done Details: OAE- normal Vision assessment: Not done Family history: Neuropsychiatric condition: No Others: Speech delay in elder sibling 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: 8 months Standing without support: Achieved Age of attainment: 12 months Walking without support: Achieved Age of attainment: 13 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 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: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Not achieved Details:: Predominantly uses non verbal communication 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:- Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 9 months Comes when called: Achieved Age of attainment: 12 months Copying parents in tasks: Achieved Age of attainment: Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: 30 minutes For tasks: 30 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Details:: Doesnt indicate for urine Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Picky eater Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: < 2 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 11 Kg Height: 84 cm Head circumference: 48.5 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Normal Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Expressive language delay Advice Intervention plan: After evaluation Evaluation: speech and language evaluation (+ REELS) General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 20-May-2026 11:15AM Demographic Details

Child's Name: Pragyan Prajapati
Age: 2 Year
Gender: Male
DOB: 2024-04-21
Mother’s age (years): 37 years
Mother’s occupation: Ophthalmologist
Father’s age (years): 41 years
Father’s occupation: government job (PWD)
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 7.5 year male
Contact: 9617139133
Referred By: Doctor
Informant: Thatipur

Presenting Concerns

Chief concerns: Speech delay

Strengths of child: Eye contact is good

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): Patterned behavior or activities: Temper tantrums
Sensory Concerns:

Details:: Cooperates for haircut and nailcut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Hypothyroidism
2. Oligohydramnios
Others:: Uterine adhesions. H/o ear infections

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Prev LSCS
Gestational Age: 36 weeks
Birth Weight: 2.6 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Admitted for NNHB (Under Phototherapy)- 5 days. Thyroid screening- normal

Past history:

Hospitalization: No Seizures: No Others: Anemia

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

Hearing assessment: Done Details: OAE- normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: No Others: Speech delay in elder sibling

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: 8 months
Standing without support: Achieved

Age of attainment: 12 months
Walking without support: Achieved

Age of attainment: 13 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

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: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Not achieved

Details:: Predominantly uses non verbal communication

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:-

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Copying parents in tasks: Achieved

Age of attainment:

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: 30 minutes
For tasks: 30 minutes

ADL Skills (Age-appropriate)-

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

Details:: Doesnt indicate for urine

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Picky eater
Food allergies: No
Junk food intake: Nil

Sleep History

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

Daily Screen Time

Duration: < 2 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 11 Kg Height: 84 cm Head circumference: 48.5 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Normal

Oromotor Examination

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

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

Impression: Expressive language delay

Advice

Intervention plan: After evaluation
Evaluation: speech and language evaluation (+ REELS)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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