16. Did the mother have any infection/ disease during pregnancy
17. Did the child cry immediately after birth
21. Was the child admitted in NICU (Neonatal Intensive Care Unit)after delivery?
22. Is Your Child Vaccinated Up to Date?
1. Abnormal (Large or small) head:
3. Frequent jerky movement of eyes:
4. Abnormal shape of ear/lips/nose/hands or legs:
6. Limp walking of your child:
7. Short length of one limb:
10. Underweight/Overweight
11. Pale, easily get tired:
14. Fits/ unconsciousness:
16. White/ brownish spots on teeth:
17. Swollen bleeding gums.
18. Itching in the night and oval spots in between fingers
19. Shortness of breath / wheezing
1. Does your child move both arms and both legs freely and equally when awake or when excited?
2. Does your child raise his or her head momentarily when lying face down?
3. Does your child respond to your voice or startles with loud sounds or becomes alert to new sound by quieting or smiling?
4. Does your child coos or able to vocalize other than crying? like ooh
5. Does your child make eye contact? (focus their eyes on the eyes of caregiver)?
6. Does your child give a social smile (reciprocal responds to mother expression or smile ie smile back at you)?
7. Does your child suck and swallow well during feeding i.e. without any choking?
I hereby confirm that the information I have provided about the medical condition of my child is true to the best of my knowledge.
