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OPD : 02-Oct-2026 11:39AM Demographic Details Child's Name: Trisha Age: 1 Year Gender: Female DOB: 2025-09-26 Mother’s age (years): 23 years Mother’s occupation: Homemaker Father’s age (years): 27 years Father’s occupation: Private job Type of family: Joint Number of family members: 3 Number of siblings: 0 Address: Kampoo Contact: 9785938323 Referred By: Doctor Informant: Mother, Grandmother Presenting Concerns Chief concerns: Delayed development Strengths of child: Interaction is good Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Oligohydramnios Others:: H/o febrile illness around 28 weeks Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Fetal distress Gestational Age: 30 weeks Birth Weight: 1.1 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: Nicu stay- 25 days for PT, VLBW, RDS, Apnea of prematurity, Anemia of prematurity, ROP. CPAP- 4 DAYS Past history: Hospitalization: No Seizures: No Investigations done- Hearing assessment: Not done Vision assessment: Done Details: ROP screening going on Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 7 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 10 months Standing without support: Not achieved Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 7 months Unidextrous grasp: Achieved Age of attainment: 9 months Pincer grasp: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Understanding gestures: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 10 months Babbling: Achieved Age of attainment: 12 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 10 months Babbling: Achieved Age of attainment: 12 months Meaningful words: 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: Achieved Age of attainment: 9 months Waving bye bye: 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 Type of Play : 1. Unoccupied Academic History: Diet History: Food preferences: Predominantly milk. Complimentary feed started Food allergies: No Sleep History Total sleep duration (night): As per age Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: No significant delay as per corrected age. Tendoachilles tightening. Mild generalised hypotonia Advice Intervention plan: IDP +PT 3/week Investigations: BERA Medications: Continue as per pediatrician Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 02-Oct-2026 11:39AM Demographic Details

Child's Name: Trisha
Age: 1 Year
Gender: Female
DOB: 2025-09-26
Mother’s age (years): 23 years
Mother’s occupation: Homemaker
Father’s age (years): 27 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 3
Number of siblings: 0
Address: Kampoo
Contact: 9785938323
Referred By: Doctor
Informant: Mother, Grandmother

Presenting Concerns

Chief concerns: Delayed development

Strengths of child: Interaction is good

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Oligohydramnios
Others:: H/o febrile illness around 28 weeks

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Fetal distress
Gestational Age: 30 weeks
Birth Weight: 1.1 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: Nicu stay- 25 days for PT, VLBW, RDS, Apnea of prematurity, Anemia of prematurity, ROP. CPAP- 4 DAYS

Past history:

Hospitalization: No Seizures: No

Investigations done-

Hearing assessment: Not done Vision assessment: Done Details: ROP screening going on

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 7 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 10 months
Standing without support: Not achieved
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 7 months

Unidextrous grasp: Achieved

Age of attainment: 9 months

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Not achieved
Pointing: Not achieved
Understanding gestures: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 10 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 10 months

Babbling: Achieved

Age of attainment: 12 months

Meaningful words: 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: Achieved

Age of attainment: 9 months
Waving bye bye: 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

Type of Play : 1. Unoccupied Academic History:

Diet History:

Food preferences: Predominantly milk. Complimentary feed started
Food allergies: No

Sleep History

Total sleep duration (night): As per age

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

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

Impression: No significant delay as per corrected age. Tendoachilles tightening. Mild generalised hypotonia

Advice

Intervention plan: IDP +PT 3/week
Investigations: BERA
Medications: Continue as per pediatrician
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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