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OPD : 24-Sep-2026 11:31AM Demographic Details Child's Name: Udayveer singh Rawat Age: 2 Year 3 Month 19 Days Gender: Male DOB: 2024-06-05 Mother’s age (years): 25 years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Farmer Type of family: Joint Number of family members: 6 Number of siblings: 1 Details of siblings (Age and sex): 4.5 year old female Address: Karaira Contact: 7697835259 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Speech delay Interaction history: Eye contact: Sustained Quality of Interaction: age-appropriate Behavioral history: Repetitive behaviors (RRBs): Running to and fro Temper tantrums Stubbornness Aggression Mouthing of objects Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Gestational Age: FT Birth Weight: 3.5 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No 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: 4 months Roll over: Achieved Age of attainment: 6 months Sitting without support: Achieved Age of attainment: 18 months Standing without support: Achieved Age of attainment: 20 months Walking without support: Achieved Age of attainment: 22 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: 18 months Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 18 months Understanding gestures: Achieved Age of attainment: Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved 2 word Phrases: Not achieved Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 24 months Meaningful words: Not achieved 2 word Phrases: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Inconsistent Drag for needs: Inconsistent Joint attention: Inconsistent Pointing: Inconsistent meaningful pointing Understanding gestures: Emerging Following commands (gesture + verbal): 1-step Answering Questions:- 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: 18 months Comes when called: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 5 minutes For tasks: 5-10 minutes ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting 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: Occasionally Sleep History Total sleep duration (night): 10 hours Afternoon nap: Yes Duration of Afternoon nap: 3-4 hours Daily Screen Time Duration: <30 minutes Examination a. Vitals: b. Anthropometry: Weight: 9.5 Kg Height: 84 cm Head circumference: 45 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1â€“12) Neuromuscular Concerns Motor delay: Gross motor and Fine motor Tone: Hypotonia Deep tendon reflexes: KJ- 1+1+, AJ-1+/1+ Superficial reflexes: Plantars- B/l flexors Oromotor Examination Drooling: Yes Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Improper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: GDD. ? Metabolic Advice Intervention plan: After evaluation Evaluation: DQ, Speech and Language evaluation Investigations: CBC, TSH, free T3, free T4, Calcium, Serum protein, Vitamin D, Vitamin B12, Creatine kinase. BERA Medications: Continue as adviced by pediatrician Follow up plan: Review with reports General recommendation- Zero Screen Time Physical interactive play No Junk food

OPD : 24-Sep-2026 11:31AM Demographic Details

Child's Name: Udayveer singh Rawat
Age: 2 Year 3 Month 19 Days
Gender: Male
DOB: 2024-06-05
Mother’s age (years): 25 years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 6
Number of siblings: 1
Details of siblings (Age and sex): 4.5 year old female
Address: Karaira
Contact: 7697835259
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Speech delay

Interaction history:

Eye contact: Sustained
Quality of Interaction: age-appropriate

Behavioral history:

Repetitive behaviors (RRBs): Running to and fro Temper tantrums Stubbornness Aggression Mouthing of objects

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Gestational Age: FT
Birth Weight: 3.5 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

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: 4 months
Roll over: Achieved

Age of attainment: 6 months
Sitting without support: Achieved

Age of attainment: 18 months
Standing without support: Achieved

Age of attainment: 20 months
Walking without support: Achieved

Age of attainment: 22 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: 18 months

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 18 months
Understanding gestures: Achieved

Age of attainment:
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 24 months

Meaningful words: Not achieved

2 word Phrases: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

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

Answering Questions:-

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: 18 months
Comes when called: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 5 minutes
For tasks: 5-10 minutes

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
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: Occasionally

Sleep History

Total sleep duration (night): 10 hours
Afternoon nap: Yes
Duration of Afternoon nap: 3-4 hours

Daily Screen Time

Duration: <30 minutes

Examination

a. Vitals:

b. Anthropometry:

Weight: 9.5 Kg Height: 84 cm Head circumference: 45 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1â€“12)

Neuromuscular Concerns

Motor delay: Gross motor and Fine motor
Tone: Hypotonia
Deep tendon reflexes: KJ- 1+1+, AJ-1+/1+
Superficial reflexes: Plantars- B/l flexors

Oromotor Examination

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

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

Impression: GDD. ? Metabolic

Advice

Intervention plan: After evaluation
Evaluation: DQ, Speech and Language evaluation
Investigations: CBC, TSH, free T3, free T4, Calcium, Serum protein, Vitamin D, Vitamin B12, Creatine kinase. BERA
Medications: Continue as adviced by pediatrician
Follow up plan: Review with reports
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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