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OPD : 14-May-2026 01:14PM Demographic Details Child's Name: Harshiv Gupta Age: 2 Year 5 Month 13 Days Gender: Male DOB: 2023-12-01 Contact: 7489936093 Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- 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 Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Diet History: Food preferences: Mixed diet Food allergies: No Junk food intake: Frequent Sleep History Total sleep duration (night): 9 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 9.3 Kg Height: 84 cm Head circumference: 43 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tendon reflexes: KJ- 3+/3+, AJ- 3+/3+ Superficial reflexes: Present Gait issues: Toe walking reduced Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Examination summary: Squint+ CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Weight bearing improved, toe walking reduced, Started cruising Advice Intervention plan: IDP 3/week Evaluation: Pediatric ophthalmologist opinion Medications: CST Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 14-May-2026 01:14PM Demographic Details

Child's Name: Harshiv Gupta
Age: 2 Year 5 Month 13 Days
Gender: Male
DOB: 2023-12-01
Contact: 7489936093

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

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

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Type of Play : 4. Parallel Academic History:

Diet History:

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

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 9.3 Kg Height: 84 cm Head circumference: 43 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tendon reflexes: KJ- 3+/3+, AJ- 3+/3+
Superficial reflexes: Present
Gait issues: Toe walking reduced

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper

Examination summary: Squint+ CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Weight bearing improved, toe walking reduced, Started cruising

Advice

Intervention plan: IDP 3/week
Evaluation: Pediatric ophthalmologist opinion
Medications: CST
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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