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OPD : 04-Aug-2026 02:07PM Demographic Details Child's Name: Rudra Pratap Bhadoriya Age: 2 Year 9 Month 29 Days Gender: Male DOB: 2023-10-06 Type of family: Joint Number of family members: 3 Number of siblings: 0 Address: Bhind Contact: 8236037457 Referred By: Doctor Informant: Mother Presenting Concerns Chief concerns: Behavioral concerns Interaction history: Eye contact: Suboptimal Quality of Interaction: avoids Behavioral history: Repetitive behaviors (RRBs): Hand flapping, looks from corner of eyes, opening closing drawer Temper tantrums Stubbornness Aggression Emotional history: Irritability Sensory Concerns: Auditory: Hypersensitive Visual: Seeks visuals Vestibular: Seeks movement Details:: Doesnt cooperate for haircut Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: Anaemia Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: FT Cry at birth: Delayed cry Resuscitation required: Yes NICU stay: Yes If yes- Duration & Indication: NICU stay for HIE for 40 days Past history: Hospitalization: No Seizures: Yes Past/Current medications: Levera, phenobarb, phenytoin 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: 6 months Roll over: Achieved Age of attainment: 12 months Sitting without support: Achieved Age of attainment: 2 years Standing without support: Achieved Age of attainment: few seconds. Recently Walking without support: Not achieved Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 13 months Pincer grasp: Not achieved Scribbling: Not achieved Drinking from cup: Not achieved Language Receptive:- Joint attention: Not achieved Pointing: Not achieved Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Not achieved Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 2 years Babbling: Not achieved Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Drag for needs: Emerging Joint attention: Absent Pointing: Absent Understanding gestures: Absent Following commands (gesture + verbal): Nil Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 13 months Stranger anxiety: Achieved Age of attainment: 18 months Waving bye bye: Achieved Age of attainment: Delayed Response to Name Call Details: Response better with mothers 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 : 3. Onlooker 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): 10-11 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ- 2+/2+, AK-+/+ Superficial reflexes: Plantars- B/l flexors Oromotor Examination Drooling: Yes Chewing: Improper Swallowing: Proper Blowing: Improper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD Advice Intervention plan: IDP 5 days/week + PMT 1/month Follow up plan: Every month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 04-Aug-2026 02:07PM Demographic Details

Child's Name: Rudra Pratap Bhadoriya
Age: 2 Year 9 Month 29 Days
Gender: Male
DOB: 2023-10-06
Type of family: Joint
Number of family members: 3
Number of siblings: 0
Address: Bhind
Contact: 8236037457
Referred By: Doctor
Informant: Mother

Presenting Concerns

Chief concerns: Behavioral concerns

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: avoids

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, looks from corner of eyes, opening closing drawer Temper tantrums Stubbornness Aggression Emotional history:
Irritability
Sensory Concerns:

Auditory: Hypersensitive
Visual: Seeks visuals
Vestibular: Seeks movement

Details:: Doesnt cooperate for haircut

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. Anaemia

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: FT
Cry at birth: Delayed cry
Resuscitation required: Yes
NICU stay: Yes
If yes- Duration & Indication: NICU stay for HIE for 40 days

Past history:

Hospitalization: No Seizures: Yes

Past/Current medications: Levera, phenobarb, phenytoin 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: 6 months
Roll over: Achieved

Age of attainment: 12 months
Sitting without support: Achieved

Age of attainment: 2 years
Standing without support: Achieved

Age of attainment: few seconds. Recently
Walking without support: Not achieved

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 13 months

Pincer grasp: Not achieved

Scribbling: Not achieved

Drinking from cup: Not achieved

Language

Receptive:-

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

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Not achieved

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 2 years

Babbling: Not achieved

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 13 months
Stranger anxiety: Achieved

Age of attainment: 18 months
Waving bye bye: Achieved

Age of attainment: Delayed

Response to Name Call

Details: Response better with mothers

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 : 3. Onlooker 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): 10-11 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ- 2+/2+, AK-+/+
Superficial reflexes: Plantars- B/l flexors

Oromotor Examination

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

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

Impression: GDD

Advice

Intervention plan: IDP 5 days/week + PMT 1/month
Follow up plan: Every month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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