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:
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 hold head erect in sitting position without bobbing ie hold her head straight?
2. Does your child reach out for an object persistently? (child should use either hands but refer if preference for one hand only) ?
3. Does your child respond to mother’s speech by looking directly at her face?
4. Does your child laugh aloud or make squealing sounds ?
5. Does your child follow an object with his /her eyes ?
6. Does your child sucks on hands ?
I hereby confirm that the information I have provided about the medical condition of my child is true to the best of my knowledge.
