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OPD : 18-Aug-2026 01:17PM Demographic Details Child's Name: Daksh Sharma Age: 3 Year 3 Month 4 Days Gender: Male DOB: 2023-05-14 Mother’s age (years): 32 years Mother’s occupation: Homemaker Father’s age (years): 35 years Father’s occupation: Private job Type of family: Joint Number of family members: 5 Number of siblings: 9 Address: D D Nagar Contact: 9039995572 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay, behavioral concerns Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Sensory Concerns: Tactile: Hypersensitive Proprioception: Seeks pressure Vestibular: Seeks movement 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: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Others: Frequent rhinitis Past/Current therapies: Nil Past/Current medications: Nil Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 10 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: 18 months Meaningful words: Achieved Age of attainment: 2.5 years 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 18 months Meaningful words: Achieved Age of attainment: 2.5 years 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:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 9 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: 9/10 Sitting tolerance- (in minutes) For interaction: 3-5 minutes For tasks: Can sit longer for tasks ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Type of Play : 4. Parallel Details:: Started arranging toys in line 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): 8 hours Afternoon nap: Yes Duration of Afternoon nap: 1 hour Sleep disturbances: Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Deep tendon reflexes: KJ_2=/2+, AJ-2+/2+ Superficial reflexes: Plantar-B/l flexors Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Expressive language delay, Difficulty in emotional regulation Advice Intervention plan: IDP 2/week + PMt 1/week Evaluation: REELS, DSM5 ADHD (Later) Follow up plan: After 1 month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-Aug-2026 01:17PM Demographic Details

Child's Name: Daksh Sharma
Age: 3 Year 3 Month 4 Days
Gender: Male
DOB: 2023-05-14
Mother’s age (years): 32 years
Mother’s occupation: Homemaker
Father’s age (years): 35 years
Father’s occupation: Private job
Type of family: Joint
Number of family members: 5
Number of siblings: 9
Address: D D Nagar
Contact: 9039995572
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay, behavioral concerns

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): running to and fro Patterned behavior or activities: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression
Sensory Concerns:

Tactile: Hypersensitive
Proprioception: Seeks pressure
Vestibular: Seeks movement

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: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No Others: Frequent rhinitis

Past/Current therapies: Nil Past/Current medications: Nil Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 10 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: 18 months

Meaningful words: Achieved

Age of attainment: 2.5 years

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 18 months

Meaningful words: Achieved

Age of attainment: 2.5 years

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:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 9 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: 9/10

Sitting tolerance- (in minutes)

For interaction: 3-5 minutes
For tasks: Can sit longer for tasks

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Type of Play : 4. Parallel Details:: Started arranging toys in line 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): 8 hours
Afternoon nap: Yes
Duration of Afternoon nap: 1 hour
Sleep disturbances:

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Deep tendon reflexes: KJ_2=/2+, AJ-2+/2+
Superficial reflexes: Plantar-B/l flexors

Oromotor Examination

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

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

Impression: Expressive language delay, Difficulty in emotional regulation

Advice

Intervention plan: IDP 2/week + PMt 1/week
Evaluation: REELS, DSM5 ADHD (Later)
Follow up plan: After 1 month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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