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OPD : 08-Aug-2026 11:02AM Demographic Details Child's Name: Arpit Rathore Age: 9 Year Gender: Male DOB: 2017-07-07 Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 12 year old male Address: Jalon Contact: 8317007305 Referred By: Healthcare worker Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Sustained Interaction: Takes time to initiate interaction with new people Quality of Interaction: age-appropriate Behavioral history: Aggression Academic Concerns: Poor scholastic performance Details:: Can copy written tasks. Difficulty in memorizing Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: around 2 Kg Cry at birth: Delayed cry Resuscitation required: Yes Details of Resuscitation: Not available NICU stay: Yes If yes- Duration & Indication: NICU stay- 1 week. No history of seizures Past history: Hospitalization: No Seizures: No 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: 3 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 7 months Standing without support: Achieved Age of attainment: 15 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: 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: Achieved Age of attainment: Language Receptive:- Joint attention: Achieved Age of attainment: 8 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Following commands: 2-step Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Achieved Age of attainment: after 2 years Meaningful words: Achieved Age of attainment: 4 years 2 word Phrases: Achieved Age of attainment: 8 years Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Achieved Age of attainment: after 2 years Meaningful words: Achieved Age of attainment: 4 years 2 word Phrases: Achieved Age of attainment: 8 years Details:: Uses 2-3 word phrases to express 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): 2-step Answering Questions:- What 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: 9 months Comes when called: Achieved Age of attainment: 12 months Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 5. Independent Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Type of Play : 5. Associative Details:: understands rules of simple games Academic History: Is child enrolled in school: Yes Type of school: Regular Grade: 3 Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Duration of Afternoon nap: Occasional Daily Screen Time Duration: < 1 hour Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination 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 Impression: Language delay Advice Evaluation: Speech and language evaluations. REELS Follow up plan: After evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 08-Aug-2026 11:02AM Demographic Details

Child's Name: Arpit Rathore
Age: 9 Year
Gender: Male
DOB: 2017-07-07
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 12 year old male
Address: Jalon
Contact: 8317007305
Referred By: Healthcare worker
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Sustained
Interaction: Takes time to initiate interaction with new people
Quality of Interaction: age-appropriate

Behavioral history:

Aggression Academic Concerns:
Poor scholastic performance Details:: Can copy written tasks. Difficulty in memorizing

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: around 2 Kg
Cry at birth: Delayed cry
Resuscitation required: Yes
Details of Resuscitation: Not available
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 1 week. No history of seizures

Past history:

Hospitalization: No Seizures: No

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: 3 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 7 months
Standing without support: Achieved

Age of attainment: 15 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:

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: Achieved

Age of attainment:

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 8 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 2-step

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Achieved

Age of attainment: after 2 years

Meaningful words: Achieved

Age of attainment: 4 years

2 word Phrases: Achieved

Age of attainment: 8 years

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Achieved

Age of attainment: after 2 years

Meaningful words: Achieved

Age of attainment: 4 years

2 word Phrases: Achieved

Age of attainment: 8 years

Details:: Uses 2-3 word phrases to express

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): 2-step

Answering Questions:-

What 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: 9 months
Comes when called: Achieved

Age of attainment: 12 months
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 5. Independent
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Type of Play : 5. Associative Details:: understands rules of simple games Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Grade: 3

Diet History:

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

Sleep History

Total sleep duration (night): 9-10 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional

Daily Screen Time

Duration: < 1 hour
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

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

Impression: Language delay

Advice

Evaluation: Speech and language evaluations. REELS
Follow up plan: After evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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