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 have difficulty in seeing either during day/night?
2. Compared with other children of his/her age, did your child have delay in walking?
3. Does your child have stiffness or floppiness and/or reduce strength in his/her arms/legs?
4. From birth till date, has your child ever had fits, or become rigid or had sudden jerks or spasms of arms, legs or whole body?
5. Compared to children of his/ her age does your child find its difficult to read or write or do simple calculations?
6. Does your child have difficulty in speaking as compare to other children of his/her age?
7. Does your child’s speech in any way different from other children of his/her age?
8. Does your child have difficulty in hearing (without Hearing Aids)?
9. Compared with other children of his/her age does your child have difficulty in sustaining attention on activities at school or home or play?
10.Compared with other children of his/her age, does your child have difficulty in learning new things?
I hereby confirm that the information I have provided about the medical condition of my child is true to the best of my knowledge.
