Development Milestone Tracker 15-18 mth

1. Name of Child:

2. Sex: 

3. Date of Birth:

4. Height in cm

5. Weight in kg

6. Blood Group:

7. Name of Parent / caregiver / Other ( Please specify Relationship /designation ):

8. Please specify Relationship.

9. Present Address (Door Number, District, State, Pin Code)

10. Mobile number (Father/ Mother/ Caregiver)

11. Age of mother at the childbirth:

12. Place of Delivery

13. Was the child born

14. Type of Delivery

15. Exposed to any

16. Did the mother have any infection/ disease during pregnancy

17. Did the child cry immediately after birth

18. weight of Child during birth

19. When was the child breast feed

20. How long was the child breast feed?

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:

2. White spot in eyes:

3. Frequent jerky movement of eyes:

4. Abnormal shape of ear/lips/nose/hands or legs:

5. Extremely short neck:

6. Limp walking of your child:

7. Short length of one limb:

8. loud sound on chest:

9. Bluish color of lips:

10. Underweight or overweight:

11. Pale, easily get tired:

12. Widening of wrist:

13. Legs bent:

14. Fits/ unconsciousness:

15. Ear abnormalities:

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 the child walk alone?

2. Does the child play by putting small things or objects into a container ?

3. Does the child make gestures on verbal request like pointing to objects ? (pointing the index finger when asked where is the ball) ?

4. Does your child follow simple one step direction as for eg sit down ?

5. Does your child say atleast two words like mama or dada like dog cat and ball even if it is not clear?

6. Does your child manipulate or explore a toy with his/her finger like poking or pulling the toy?

I hereby confirm that the information I have provided about the medical condition of my child is true to the best of my knowledge.