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OPD : 18-Aug-2026 03:15PM Demographic Details Child's Name: Prince Soni Age: 5 Year 7 Month 13 Days Gender: Male DOB: 2021-01-05 Type of family: Joint Number of family members: 9 Number of siblings: 0 Address: Tikamgarh Contact: 6268893295 Referred By: Doctor Informant: Parents, uncle Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): Hand flapping, toe walking, looking from corner of eye Hyperactivity Inattention Impulsivity Stubbornness Aggression Sensory Concerns: Auditory: 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 Indication for LSCS (if applicable): Non progression of labor Gestational Age: FT Birth Weight: 3 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: Yes If yes- Duration & Indication: 15 days ? Past history: Hospitalization: No Seizures: No Investigations done- Family history: Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 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: 2.5 years Walking without support: Achieved Age of attainment: 3 years 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: 12 months Babbling: Achieved Age of attainment: 2.5 years Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Not achieved Complete sentences: Not achieved Expressive:- Cooing: Achieved Age of attainment: 12 months Babbling: Achieved Age of attainment: 2.5 years Meaningful words: Achieved Age of attainment: 3 years 2 word Phrases: Not achieved Complete sentences: Not achieved Details:: Uses Papa, mummy Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Consistent Drag for needs: Consistent Joint attention: Consistent Pointing: Consistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Absent Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 6 years 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: 10/10 Sitting tolerance- (in minutes) For interaction: 10-15 minutes. Fidgetiness+ ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 4. Needs minimal assistance Toilet training: 3. Needs significant assistance Dressing: 1. Dependent Undressing: 2. Started attempting Type of Play : Details:: Destructive play, pushes children Academic History: Is child enrolled in school: No Diet History: Food preferences: Mixed Food allergies: No Junk food intake: Daily Sleep History Total sleep duration (night): 9-10 hours Afternoon nap: No Daily Screen Time Duration: > 2 hours Type of screen: Mobile 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 Oromotor Examination Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper Examination summary: Mild Hypotonia, DTR- KJ2+/2+, AJ-2+/2+. Plantar- B/l flexors CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ?ID Advice Intervention plan: IDP 1/week + PMT 1/week Evaluation: DQ, Speech and language evaluation Investigations: MRI Brain. CBC, Calcium, Vitamin D, Vitamin B12, free T3, free T4, TSH Medications: As adviced by pediatrician Follow up plan: After evaluation General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 18-Aug-2026 03:15PM Demographic Details

Child's Name: Prince Soni
Age: 5 Year 7 Month 13 Days
Gender: Male
DOB: 2021-01-05
Type of family: Joint
Number of family members: 9
Number of siblings: 0
Address: Tikamgarh
Contact: 6268893295
Referred By: Doctor
Informant: Parents, uncle

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): Hand flapping, toe walking, looking from corner of eye Hyperactivity Inattention Impulsivity Stubbornness Aggression
Sensory Concerns:

Auditory: 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
Indication for LSCS (if applicable): Non progression of labor
Gestational Age: FT
Birth Weight: 3 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: Yes
If yes- Duration & Indication: 15 days ?

Past history:

Hospitalization: No Seizures: No

Investigations done-

Family history:

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 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: 2.5 years
Walking without support: Achieved

Age of attainment: 3 years
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: 12 months

Babbling: Achieved

Age of attainment: 2.5 years

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 12 months

Babbling: Achieved

Age of attainment: 2.5 years

Meaningful words: Achieved

Age of attainment: 3 years

2 word Phrases: Not achieved

Complete sentences: Not achieved

Details:: Uses Papa, mummy

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

Echolalia: Absent

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 6 years
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: 10/10

Sitting tolerance- (in minutes)

For interaction: 10-15 minutes. Fidgetiness+

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 4. Needs minimal assistance
Toilet training: 3. Needs significant assistance
Dressing: 1. Dependent
Undressing: 2. Started attempting

Type of Play : Details:: Destructive play, pushes children Academic History:

Is child enrolled in school: No

Diet History:

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

Sleep History

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

Daily Screen Time

Duration: > 2 hours
Type of screen: Mobile

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

Oromotor Examination

Chewing: Proper
Swallowing: Proper
Blowing: Proper
Sucking: Proper

Examination summary: Mild Hypotonia, DTR- KJ2+/2+, AJ-2+/2+. Plantar- B/l flexors CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: ?ID

Advice

Intervention plan: IDP 1/week + PMT 1/week
Evaluation: DQ, Speech and language evaluation
Investigations: MRI Brain. CBC, Calcium, Vitamin D, Vitamin B12, free T3, free T4, TSH
Medications: As adviced by pediatrician
Follow up plan: After evaluation
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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