Name of Student:

Date of Birth:

IQ Level/Class (as per psychologist report):

Blood Group:

Sex/Gender:

Languages Spoken & Mother Tongue:

Childhood History (if child is MR what is level, Mild, Moderate, Severe):

Family History of any Retardation / Disability (any parent's family members having the same syndrome):

Immunization History (mention all doses given, any pending doses?):

Developmental Milestones (talking, walking at what age, etc):

General Behavior:

Tell us about your Child
Motor Functional Activities (Fine & Gross Motor Skills, etc.)
Eye & Hand Co-Ordination:

Are there any particular time in the day, when the child's behavior is more severe, if yes, when is it? Does it happen regularly? Who is the most affected? :

Was the child asked to do something, or was the child refused something, prior to the Behaviour, if yes, please specify, What do you or others generally do, immediately to calm the child:

Was the child asked to do something, or was the child refused something, prior to the Behaviour, if yes, please specify, What do you or others generally do, immediately to calm the child:

Please provide us with the Complete Medical History / Disorders, etc. of the Child (also Pre Natal / Natal / Post Natal, Complications, etc.):

Medication History (allopathic / homeopathic medicine in the past / current prescribed by a physician & name of physician/doctor):

Hobbies / Sports / Games / Likes and Dislikes, etc.:

Past time Behavior / Leisure Activities, etc.:

Problems in Speech / Physical Movements, etc.:

Nature, Name and Full Address of the School he attended earlier (Special / Integrated / Normal, Dates, Class till, etc.), How was his Attendance ?:

How is his Interaction with People, be it Friends, Neighbors, Relatives at Social Gatherings, Strangers, etc. (if any) :

Does your Child suffer with any Convulsion Problem, Epilepsy, Fits, Allergies, etc (if any kindly provide full details with medication) :

Major Emotional & Behavioral Problem of the Child:

Type of Family (joint/nuclear & number of persons, time spent by parents and siblings):

What kind of Help/Support/Guidance are you looking for from us
(in brief, like want them to be independent, basic education via national open school, etc.):

Anything you would like to inform us about, (about his toilet training, about his fooding habits, obsession, ocd, favorite food, other remarks etc):

Who is your Childs Doctor / Physician (Name and Contact Details) :

List of Medications taken or taking regularly, If any :

Is your Child Toilet Trained?:

                    Yes      No

Fathers Name:

Fathers Mobile Number:

Occupation/Designation/Business:

Caste (Punjabi/Sindhi/Marwari/Bengali/Assamese/Christian/Muslim,etc):

Mothers Name:

Mothers Mobile Number:

Occupation/Designation/Business:

Caste (Punjabi/Sindhi/Marwari/Bengali/Assamese/Christian/Muslim,etc):

Full Residential/Postal Address:

City:

Pin:

Country:

Telephone (incl.country & city code):

Mobile (incl.country & city code):

Facsimile (incl.country & city code):

How did you get to know us:

E-Mail: