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OPD : 12-May-2026 09:39AM Demographic Details Child's Name: Anaija Shah Age: 4 Year 1 Month 2 Days Gender: Female DOB: 2022-04-10 Contact: 8871177040 Interaction history: Eye contact: Sustained Behavioral history: Stubbornness 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: Absent Answering Questions:- Social Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Type of Play : 2. Isolated Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 1-2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 10 Kg Height: 86 cm Head circumference: 48 cm c. General Examination Dysmorphology: NAD Neurocutaneous markers: NAD d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Deep tendon reflexes: KJ- 1+/1+, AJ- 1+/1+ Superficial reflexes: Plantars- flexors/flexors Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: IDP 2/week (Home based) Investigations: Whole Exome Sequencing Medications: Syp calcium 5 ml OD Follow up plan: After 1 month General recommendation- Zero Screen Time

OPD : 12-May-2026 09:39AM Demographic Details

Child's Name: Anaija Shah
Age: 4 Year 1 Month 2 Days
Gender: Female
DOB: 2022-04-10
Contact: 8871177040

Interaction history:

Eye contact: Sustained

Behavioral history:

Stubbornness

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: Absent

Answering Questions:-

Social

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

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

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: No

Diet History:

Food preferences: Mixed
Food allergies: No

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1-2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 10 Kg Height: 86 cm Head circumference: 48 cm

c. General Examination

Dysmorphology: NAD Neurocutaneous markers: NAD

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Deep tendon reflexes: KJ- 1+/1+, AJ- 1+/1+
Superficial reflexes: Plantars- flexors/flexors

Oromotor Examination

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

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

Impression: GDD

Advice

Intervention plan: IDP 2/week (Home based)
Investigations: Whole Exome Sequencing
Medications: Syp calcium 5 ml OD
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time

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