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Demographic Details Child's Name: Hanu Pathak Age: 3 Year 3 Month 15 Days Gender: Male DOB: 2022-11-22 Mother’s age (years): 38 years Mother’s occupation: Homemaker Father’s age (years): 38 years Father’s occupation: Service Type of family: Nuclear Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 1- 10 year old male Address: Gole ka mandir Contact: 8770351340 Referred By: Doctor Presenting Concerns Chief concerns: Speech delay Duration of symptoms: Noticed since 1 month Interaction history: Eye contact: Fleeting Interaction: Better with parents Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hand flapping, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession Sensory Concerns: Vestibular: Seeks movement 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: 3.5 Kg Cry at birth: Cried immediately after birth NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current medications: No 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: 3 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 9 months Walking without support: Achieved Age of attainment: 14 months 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: 8 months Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Drag for needs: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Not achieved Asking for food and toilet: Not achieved Response to Name Call Details: 2/10 Sitting tolerance- (in minutes) For interaction: Less than a minute For tasks: Better ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 2. Isolated Outdoor play duration: Irregular Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Vibgyor Grade: Play group Location: Gole ka mandir Diet History: Food preferences: Picky eater, Craving for sweets Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: < 1 hour Examination a. Vitals: b. Anthropometry: Weight: 12.8kg Height: 90 cm Head circumference: 48 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week, PMT 1/week Investigations: Evaluations next month (DQ, ISAA, DSM5 ASD) General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Hanu Pathak
Age: 3 Year 3 Month 15 Days
Gender: Male
DOB: 2022-11-22
Mother’s age (years): 38 years
Mother’s occupation: Homemaker
Father’s age (years): 38 years
Father’s occupation: Service
Type of family: Nuclear
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 1- 10 year old male
Address: Gole ka mandir
Contact: 8770351340
Referred By: Doctor

Presenting Concerns

Chief concerns: Speech delay
Duration of symptoms: Noticed since 1 month

Interaction history:

Eye contact: Fleeting
Interaction: Better with parents
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, spinning Patterned behavior or activities: Hyperactivity Inattention Impulsivity Object obsession
Sensory Concerns:

Vestibular: Seeks movement

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: 3.5 Kg
Cry at birth: Cried immediately after birth
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current medications: No 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: 3 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 9 months
Walking without support: Achieved

Age of attainment: 14 months

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: 8 months
Pointing: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Drag for needs: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Not achieved
Asking for food and toilet: Not achieved

Response to Name Call

Details: 2/10

Sitting tolerance- (in minutes)

For interaction: Less than a minute
For tasks: Better

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Outdoor play duration: Irregular Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Vibgyor
Grade: Play group
Location: Gole ka mandir

Diet History:

Food preferences: Picky eater, Craving for sweets

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: < 1 hour

Examination

a. Vitals:

b. Anthropometry:

Weight: 12.8kg Height: 90 cm Head circumference: 48 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper

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

Advice

Intervention plan: IDP 2/week, PMT 1/week
Investigations: Evaluations next month (DQ, ISAA, DSM5 ASD)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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