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OPD : 10-Jun-2026 01:24PM Demographic Details Child's Name: Aditya Rajput Age: 3 Year 9 Month 24 Days Gender: Male DOB: 2022-08-17 Mother’s age (years): 24 years Mother’s occupation: Homemaker Father’s age (years): 32 years Father’s occupation: Farming Type of family: Joint Number of family members: 6 Number of siblings: 0 Address: Datia Contact: 9340172766 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Duration of symptoms: Since early infancy Interaction history: Eye contact: Fleeting Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Handflapping, stimming, running to and fro Patterned behavior or activities: Arranges toys in lines, spins wheels Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Encopresis Sensory Concerns: Tactile: Hypersensitive Auditory: Hypersensitive Proprioception: Seeks pressure Vestibular: Seeks movement Details:: Doesnt cooperate for haircut and nailcut 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): Cord around neck Gestational Age: FT Birth Weight: around 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Others: Admitted for 2-3 days for febrile seizure Past/Current therapies: Nil Past/Current medications: Syp Gudlex Plus for constipation Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: Yes Others: ID in paternal uncle 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: 16 months Walking without support: Achieved Age of attainment: 18 months Running: Achieved Age of attainment: Climbing upstairs: Achieved Age of attainment: Climbing downstairs: Achieved Age of attainment: Hopping: 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 Scribbling: Achieved Age of attainment: Drinking from cup: Achieved Age of attainment: Buttoning / Unbuttoning: Not achieved 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: 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:- 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:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: Comes when called: Achieved Age of attainment: Copying parents in tasks: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Details: 10/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: 3-5 minutes ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Eats food of his choice by himself Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: > 2 hours Type of screen: Mobile and TV Examination a. Vitals: b. Anthropometry: Weight: 14 Kg Height: 102 cm Head circumference: 48 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Evaluation: DQ, ISAA, Speech and language evaluation Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 10-Jun-2026 01:24PM Demographic Details

Child's Name: Aditya Rajput
Age: 3 Year 9 Month 24 Days
Gender: Male
DOB: 2022-08-17
Mother’s age (years): 24 years
Mother’s occupation: Homemaker
Father’s age (years): 32 years
Father’s occupation: Farming
Type of family: Joint
Number of family members: 6
Number of siblings: 0
Address: Datia
Contact: 9340172766
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay
Duration of symptoms: Since early infancy

Interaction history:

Eye contact: Fleeting
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Handflapping, stimming, running to and fro Patterned behavior or activities: Arranges toys in lines, spins wheels Hyperactivity Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Encopresis
Sensory Concerns:

Tactile: Hypersensitive
Auditory: Hypersensitive
Proprioception: Seeks pressure
Vestibular: Seeks movement

Details:: Doesnt cooperate for haircut and nailcut

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): Cord around neck
Gestational Age: FT
Birth Weight: around 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Others: Admitted for 2-3 days for febrile seizure

Past/Current therapies: Nil Past/Current medications: Syp Gudlex Plus for constipation Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: Yes Others: ID in paternal uncle

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: 16 months
Walking without support: Achieved

Age of attainment: 18 months
Running: Achieved

Age of attainment:
Climbing upstairs: Achieved

Age of attainment:
Climbing downstairs: Achieved

Age of attainment:
Hopping: 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

Scribbling: Achieved

Age of attainment:

Drinking from cup: Achieved

Age of attainment:

Buttoning / Unbuttoning: Not achieved

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: 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:-

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:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment:
Comes when called: Achieved

Age of attainment:
Copying parents in tasks: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Details: 10/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: 3-5 minutes

ADL Skills (Age-appropriate)-

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

Details:: Eats food of his choice by himself

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

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

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile and TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 14 Kg Height: 102 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

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

Advice

Evaluation: DQ, ISAA, Speech and language evaluation
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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