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OPD : 03-Apr-2026 07:19PM Demographic Details Child's Name: Aadhya Prajapati Age: 8 Month 19 Days Gender: Female DOB: 2025-07-15 Mother’s age (years): 30 years Mother’s occupation: Housewife Father’s age (years): 32 years Father’s occupation: Teacher Type of family: Joint Number of family members: 7 Number of siblings: 1 Address: Chhatarpur Contact: 6261620702 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed development Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: Post term Birth Weight: 2.9 Kg Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 8 days, HIE2 Past history: Hospitalization: Yes Others: At 6 month- for seizures. Last seizures 3 days back. Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Language Receptive:- Joint attention: Not achieved Expressive:- Cooing: Not achieved Expressive:- Cooing: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Absent Answering Questions:- Social Social smile: Achieved Age of attainment: 4 months Stranger anxiety: Not achieved Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Diet History: Food preferences: Complimentary feed started 1 mon back Food allergies: No Sleep History Total sleep duration (night): 4-5 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 4.9 Kg Height: 60 cm Head circumference: 36 cm c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Bulk of muscles: Generalised wasting Tone: Hypertonia Deep tendon reflexes: KJ-3+/3+, AJ 2+/2+ Superficial reflexes: Plantar- B/l extensors Other: AF- closed, PF- closed Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP (+PT) Investigations: BERA; CBC, Calcium, Vit D2, Thyroid profile Medications: Contined AEDs as advised by pediatrician General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 03-Apr-2026 07:19PM Demographic Details

Child's Name: Aadhya Prajapati
Age: 8 Month 19 Days
Gender: Female
DOB: 2025-07-15
Mother’s age (years): 30 years
Mother’s occupation: Housewife
Father’s age (years): 32 years
Father’s occupation: Teacher
Type of family: Joint
Number of family members: 7
Number of siblings: 1
Address: Chhatarpur
Contact: 6261620702
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed development

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: Post term
Birth Weight: 2.9 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 8 days, HIE2

Past history:

Hospitalization: Yes Others: At 6 month- for seizures. Last seizures 3 days back.

Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved

Expressive:-

Cooing: Not achieved

Expressive:-

Cooing: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Absent

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 4 months
Stranger anxiety: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Diet History:

Food preferences: Complimentary feed started 1 mon back
Food allergies: No

Sleep History

Total sleep duration (night): 4-5 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 4.9 Kg Height: 60 cm Head circumference: 36 cm

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Bulk of muscles: Generalised wasting
Tone: Hypertonia
Deep tendon reflexes: KJ-3+/3+, AJ 2+/2+
Superficial reflexes: Plantar- B/l extensors
Other: AF- closed, PF- closed

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Proper

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

Advice

Intervention plan: IDP (+PT)
Investigations: BERA; CBC, Calcium, Vit D2, Thyroid profile
Medications: Contined AEDs as advised by pediatrician
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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