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OPD : 28-Jul-2026 02:58PM Demographic Details Child's Name: Pravin Sharma Age: 14 Year 10 Month 28 Days Gender: Male DOB: 2011-08-30 Mother’s age (years): 40 years Mother’s occupation: Homemaker Father’s age (years): 40 years Father’s occupation: Transport Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 12 years Address: Bhind Contact: 7000313227 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Delayed milestones Duration of symptoms: Since infancy Interaction history: Eye contact: Suboptimal Behavioral history: Sensory Concerns: Auditory: Fear of loud sounds Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Mode of Delivery: NVD Gestational Age: FT Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay- 2 months. HIE. Discharged on AEDS. Given on and off. Past history: Hospitalization: No Seizures: Yes Others: Last seizure episode 2 years back. Past/Current therapies: Physiotherapy at home Investigations done- Hearing assessment: Done Vision assessment: Done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: Partial. 5 years Roll over: Achieved Age of attainment: Delayed Sitting without support: Achieved Age of attainment: 4 years Standing without support: Achieved Age of attainment: 6 years Walking without support: Not achieved Fine Motor Bidextrous grasp: Not achieved Unidextrous grasp: Not achieved Pincer grasp: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: Delayed Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: Delayed Babbling: Not achieved Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: Delayed Babbling: Not achieved Meaningful words: Not achieved 2 word Phrases: Not achieved Complete sentences: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Emerging Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Social Social smile: Achieved Age of attainment: 3 months Stranger anxiety: Achieved Age of attainment: 12 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 : 3. Onlooker Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Nil Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Duration of Afternoon nap: Occasional Daily Screen Time Duration: > 5 hours Type of screen: TV Examination a. Vitals: b. Anthropometry: Weight: 30 Kg Head circumference: 51 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypertonia Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Improper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Mixed CP. GDD Advice Intervention plan: After evaluation Evaluation: Neuromotor assessment Follow up plan: After evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 28-Jul-2026 02:58PM Demographic Details

Child's Name: Pravin Sharma
Age: 14 Year 10 Month 28 Days
Gender: Male
DOB: 2011-08-30
Mother’s age (years): 40 years
Mother’s occupation: Homemaker
Father’s age (years): 40 years
Father’s occupation: Transport
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 12 years
Address: Bhind
Contact: 7000313227
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Delayed milestones
Duration of symptoms: Since infancy

Interaction history:

Eye contact: Suboptimal

Behavioral history:

Sensory Concerns:

Auditory: Fear of loud sounds

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Mode of Delivery: NVD
Gestational Age: FT
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay- 2 months. HIE. Discharged on AEDS. Given on and off.

Past history:

Hospitalization: No Seizures: Yes Others: Last seizure episode 2 years back.

Past/Current therapies: Physiotherapy at home Investigations done-

Hearing assessment: Done Vision assessment: Done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: Partial. 5 years
Roll over: Achieved

Age of attainment: Delayed
Sitting without support: Achieved

Age of attainment: 4 years
Standing without support: Achieved

Age of attainment: 6 years
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Not achieved

Unidextrous grasp: Not achieved

Pincer grasp: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: Delayed
Pointing: Not achieved
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: Delayed

Babbling: Not achieved

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: Delayed

Babbling: Not achieved

Meaningful words: Not achieved

2 word Phrases: Not achieved

Complete sentences: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging
Drag for needs: Emerging
Joint attention: Emerging
Pointing: Absent
Understanding gestures: Absent
Following commands (gesture + verbal): Nil

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 3 months
Stranger anxiety: Achieved

Age of attainment: 12 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 : 3. Onlooker Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No
Duration of Afternoon nap: Occasional

Daily Screen Time

Duration: > 5 hours
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Weight: 30 Kg Head circumference: 51 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypertonia

Oromotor Examination

Drooling: Yes
Chewing: Improper
Swallowing: Improper
Blowing: Improper
Sucking: Improper

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

Impression: Mixed CP. GDD

Advice

Intervention plan: After evaluation
Evaluation: Neuromotor assessment
Follow up plan: After evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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