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OPD : 22-Oct-2026 01:53PM Demographic Details Child's Name: Rudra Aswal Age: 3 Year 1 Month 17 Days Gender: Male DOB: 2023-09-05 Contact: 7773013437 Current Improvements: Breatholding spells reduced, better control in walking Current concerns: Speech delay Current medications: Syp Histafer, Syp Multivitamin, Vit D Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Hyperactivity Inattention Birth & Perinatal History: Antenatal History Natal and Postnatal History: Past history: Investigations done- Family history: Developmental History: Gross Motor Fine Motor Language Expressive:- Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Social Response to Name Call Sitting tolerance- (in minutes) For interaction: 10-15 minutes For tasks: 15-20 minutes ADL Skills (Age-appropriate)- Eating: 3. Needs significant assistance Bathing: 3. Needs significant assistance Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : 4. Parallel Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Ocacsional Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 2 hours Daily Screen Time Duration: Zero Examination a. Vitals: b. Anthropometry: Weight: 13.7 Kg Height: 92 cm Head circumference: 47 cm c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Oromotor Examination Examination summary: PICA. GDD CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: LDP 3/week + PMT 1/15 days Evaluation: DQ, Speech and Language Evaluation Investigations: CBC, Vitamin D after 3 months Medications: Syp Histafer 30mg/5ml 5 ml BD, syp Multivitamin a to Z, Sol Uprise D360,000IU weekly for 6 weeks Follow up plan: Next month General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 22-Oct-2026 01:53PM Demographic Details

Child's Name: Rudra Aswal
Age: 3 Year 1 Month 17 Days
Gender: Male
DOB: 2023-09-05
Contact: 7773013437
Current Improvements: Breatholding spells reduced, better control in walking
Current concerns: Speech delay
Current medications: Syp Histafer, Syp Multivitamin, Vit D

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Hyperactivity Inattention

Birth & Perinatal History: Antenatal History

Natal and Postnatal History:

Past history:

Investigations done-

Family history:

Developmental History:

Gross Motor

Fine Motor

Language

Expressive:-

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Consistent
Drag for needs: Consistent
Joint attention: Consistent
Pointing: Inconsistent meaningful pointing
Understanding gestures: Emerging
Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present

Social

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 10-15 minutes
For tasks: 15-20 minutes

ADL Skills (Age-appropriate)-

Eating: 3. Needs significant assistance
Bathing: 3. Needs significant assistance
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : 4. Parallel Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 2 hours

Daily Screen Time

Duration: Zero

Examination

a. Vitals:

b. Anthropometry:

Weight: 13.7 Kg Height: 92 cm Head circumference: 47 cm

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Oromotor Examination

Examination summary: PICA. GDD CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Advice

Intervention plan: LDP 3/week + PMT 1/15 days
Evaluation: DQ, Speech and Language Evaluation
Investigations: CBC, Vitamin D after 3 months
Medications: Syp Histafer 30mg/5ml 5 ml BD, syp Multivitamin a to Z, Sol Uprise D360,000IU weekly for 6 weeks
Follow up plan: Next month
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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