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OPD : 03-Jun-2026 11:42AM Demographic Details Child's Name: Adhiraj Agrawal Age: 1 Year 8 Month 9 Days Gender: Male DOB: 2024-09-25 Mother’s age (years): 43 years Mother’s occupation: Homemaker Father’s age (years): Deceased 2 mon back Type of family: Joint Number of family members: 17 Number of siblings: 2 Details of siblings (Age and sex): 13,12 year females Address: Chhatarpur Contact: 6266385698 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delaye walking Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: 28 weeks Birth Weight: 900g Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Nicu stay- 22 days. RDS. Prematurity ELBW Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Done Details: Laser phtocoagulation B/l eyes for ROP Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 7 months Roll over: Achieved Age of attainment: 12 months Sitting without support: Achieved Age of attainment: 13 months Standing without support: Not achieved Walking without support: Not achieved 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 Drinking from cup: Achieved Age of attainment: 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: 7 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 7 months Babbling: Achieved Age of attainment: 9 months Meaningful words: Achieved Age of attainment: 12 months 2 word Phrases: Not achieved 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: 4 months Stranger anxiety: Achieved Age of attainment: 12 months Waving bye bye: Achieved Age of attainment: 13 months Comes when called: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed. Bottlefeeding. Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours 2 naps Sleep disturbances: No Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 77 cm Head circumference: 45.5 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+ Superficial reflexes: Plantars- extensors/extensors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Spastic diplegic cerebral palsy Advice Evaluation: Neuromotor assessment 1 Follow up plan: Review after report General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Jun-2026 11:42AM Demographic Details

Child's Name: Adhiraj Agrawal
Age: 1 Year 8 Month 9 Days
Gender: Male
DOB: 2024-09-25
Mother’s age (years): 43 years
Mother’s occupation: Homemaker
Father’s age (years): Deceased 2 mon back
Type of family: Joint
Number of family members: 17
Number of siblings: 2
Details of siblings (Age and sex): 13,12 year females
Address: Chhatarpur
Contact: 6266385698
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delaye walking

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: 28 weeks
Birth Weight: 900g
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- 22 days. RDS. Prematurity ELBW

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: Laser phtocoagulation B/l eyes for ROP

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 7 months
Roll over: Achieved

Age of attainment: 12 months
Sitting without support: Achieved

Age of attainment: 13 months
Standing without support: Not achieved
Walking without support: Not achieved

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

Drinking from cup: Achieved

Age of attainment:

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: 7 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 7 months

Babbling: Achieved

Age of attainment: 9 months

Meaningful words: Achieved

Age of attainment: 12 months

2 word Phrases: Not achieved

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: 4 months
Stranger anxiety: Achieved

Age of attainment: 12 months
Waving bye bye: Achieved

Age of attainment: 13 months
Comes when called: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed. Bottlefeeding.
Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours 2 naps
Sleep disturbances: No

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 77 cm Head circumference: 45.5 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia
Deep tendon reflexes: KJ-3+/3+, AJ-2+/2+
Superficial reflexes: Plantars- extensors/extensors

Oromotor Examination

Drooling: Yes
Chewing: Proper
Swallowing: Proper
Blowing: Improper
Sucking: Improper

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

Impression: Spastic diplegic cerebral palsy

Advice

Evaluation: Neuromotor assessment 1
Follow up plan: Review after report
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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