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Bio Data

Name : {{ $details['name'] }}

Date Of Birth : {{ $details['dob'] }}

Age :

@php $classLabels = [ "0" => "Play group", "00" => "KG-1", "000" => "KG-2" ]; @endphp

Class : {{ $classLabels[$details['class']] ?? $details['class'] }}

GR Number : {{ $details['gr_number'] }}

MR Number : {{ $details['mrr'] }}

Guardian Name : {{ $details['guardianname'] }}

Address : {{ $details['address'] }}

Blood Group : {{ $details['blood_group'] }}

Gender : {{ $details['gender'] }}

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School @foreach ($school as $item) @if ($details['school'] == $item->id) @endif @endforeach

City @foreach ($city as $item) @if ($details['city'] == $item->id) @endif @endforeach

Area @foreach ($area as $item) @if ($details['area'] == $item->id) @endif @endforeach

Date Of Birth

Age

Emergency Contact Number

GR Number

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Any Known Medical Condition

Comment/Findings

Vitals/BMI

Question No.1: Height :cm(s)

Question No.2: Weight :kg(s)

Question No.3: BMI (Red field means abnomality )

Question No.4: Body Temperature

Question No.5: Blood Pressure (Systolic) (Red field means abnomality )

Question No.6: Blood Pressure (Diastolic) (Red field means abnomality )

Question No.7: Pulse (Red field means abnomality )

Comment/Findings

General Apperance

Question No.8: Normal Posture/Gait

Question No.9: Mental Status

Question No.10: Look For jaundice

Question No.11: Look For anemia

Question No.12: Look For Clubbing

Question No.13: Look for Cyanosis

Question No.14: Skin

Question No.15: Breath

Comment/Findings

Inspect Hygiene

Question No.16: Nails

Question No.17: Uniform or shoes

Question No.18: Lice/nits

Question No.19: Discuss hygiene routines and practices.

Comment/Findings

Head and Neck examination

Question No:20 Hair and Scalp

Question No.21: Any Hair Problem

Question No.22: Scalp

Question No.23: Hair distribution

Comment/Findings

Eye:

Question No.24: Visual acuity using Snellen’s (Right Eye) chart

Question No.24: Visual acuity using Snellen’s (Left Eye) chart

Question No.25: Normal ocular alignment

Question No.26: Normal eye inspection

Question No.27: Normal Color vision

Question No.28: Nystagmus

Comment/Findings

Ears:

Question No.29: Normal ears shape and position

Question No.30: Ear examination

Question No.31: Conclusion of hearing test with Rinner and Weber

Comment/Findings

Nose:

Question No.32:External nasal examinaton

Question No.33:perform a nasal patency test [which involves gently closing one nostril at a time to assess the patient's ability to breathe through each nostril]

Comment/Findings

Lead Exposure

Question No. 48: Do you Frequently put things in his/her mouth such as toys, jewelry, or keys?

Question No.49: Does your child eat non-food items(pica)?

Question No. 50: Do you frequently come in contact with an adult whose job involves exposure to lead?

Question No. 51: Do you frequently come in contact with an adult whose hobby involves exposure to lead?

Comment/Findings

Oral:

Question No.34: Assess gingiva

Question No.35: Are there dental caries

Comment/Findings

Throat:

Question No.36: Examine tonsils

Question No.37: Normal Speech development

Question No.38:Any Neck swelling

Question No.39: Examine lymph node

Specify lymph node

Specify Any Neck swelling

Comment/Findings

Chest:

Question No.40 Any visible chest deformity

Question No.41 Lung Auscultation

Question No.42: Cardiac Auscultation

Comment/Findings

Abdomen:

Question No.43: Did you observe any distension, scars, or masses on the child's abdomen?

Question No.44 Any history of abdominal Pain

Specify Abdominal Pain

Comment/Findings

Musculoskeletal

Question No.45: Did you observe any limitations in the child's range of joint motion during your examination?*

Specify limitations in the child's range of joint motion during your examination?*

Question No.46: Spinal curvature assessment (tick positive finding)

Question No.47: side-to-side curvature in the spine resembling

Question No.48: Adams forward bend test

Question No.49: Any foot or toe abnormalities

Comment/Findings

Vaccination:

Question No.50: Have EPI immunization card?

Reason of not being vaccinated

Question No.50: Mark all the vaccinations that are completed

Comment/Findings

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Lead exposure

Question.51:Do you Frequently put things in his/her mouth such as toys, jewelry, or keys?

Question.52: Does your child eat non-food items(pica)?

Question.53: Do you frequently come in contact with an adult whose job involves exposure to lead?

Question.54: Do you frequently come in contact with an adult whose hobby involves exposure to lead?

Comment/Findings

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Miscellaneous

Question No.55:Do you have any Allergies

Specify Allergies

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Question No.56:Girls above 8 years old ask age of Menarche:

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Question No.57:Inquire about urinary frequency, urgency, and any pain or discomfort during urination.

Question No.58:Any menstrual abnormality.

Specify Menstrual Abnormality

Comment/Findings

Psychological

Cognitive: Does your child try to solve problems, like figuring out how to get a toy from a box?

Question No.60: Self-Esteem: How would you rate your overall self-esteem and self-confidence?

Question No.61: Energy Levels: How would you describe your energy levels throughout a typical day?

Question No.62: Coping Strategies: When faced with challenges, what are your typical coping mechanisms?

Question No.63: Sleep Quality: How would you rate the quality of your sleep on average?

Question No.64: Stress Levels: How often have you felt overwhelmed or stressed in the last few weeks?

Question No.65: Mood Assessment: How would you describe your overall mood during the day?

Question No.66: Family Relationships: How would you describe the quality of your relationships with family members?

Question No.67: Problem-Solving Skills: How well does you handle challenges and solve problems?

Question No.68: Sleep Patterns: How many hours of sleep does you typically get on a school night?

Question No.69: followup required?:

Question No.70: Referred By:

Question No.71: Referred To:

Motor: Can your child draw a line or circle?

Language: Can your child form 2- to 3-word phrases (e.g., \"want juice\")?

Language: Does your child ask simple questions like \"What's that?\"

Social-Emotional: Does your child play pretend (e.g., feeding a doll)?

Social-Emotional: Does your child show awareness of other people's feelings?

Adaptive: Can your child take off some clothes without help?

Adaptive: Is your child starting to show interest in potty training?

Cognitive: Can your child count to 5 or recognize some colors?

Cognitive: Can your child follow two-step directions (e.g., \"Get your shoes and put them by the door\")?

Motor: Can your child hop on one foot or catch a large ball?

Motor: Can your child use scissors to cut paper?

Language: Can your child tell a short story or describe an object?

Language: Are you able to understand what your child is saying most of the time?

Social-Emotional: Does your child play cooperatively with other children?

Social-Emotional: Does your child express emotions appropriately (e.g., anger, frustration)?

Adaptive: Can your child dress and undress without help?

Adaptive: Can your child use the toilet independently?

Findings by Psychologist(Add/Edit)

Comment/Findings

Findings by Psychologist(Comment)

PRE-PRIMARY PSYCHOLOGICAL SCREENER

DEVELOPMENTAL SCREENING

Age: 12–24.9 Months
Grade: Play Group

Instructions: Read each statement carefully and select the answer that best describes your child’s behavior during the last 30 days.

Cognitive: Does your child try to solve problems, like figuring out how to get a toy from a box?

Cognitive: Does your child imitate household tasks (e.g., sweeping, talking on phone)?

Motor: Can your child walk without help?

Motor: Can your child stack two or more blocks?

Language: Does your child point to objects when named?

Language: Can your child say at least 5–10 words?

Social-Emotional: Does your child show affection to familiar people?

Social-Emotional: Does your child get upset when separated from you?

Adaptive: Can your child feed themselves with fingers or a spoon?

Adaptive: Does your child try to brush teeth or wash hands with help?

Cognitive Result:

Cognitive Total Score:

Motor Result:

Motor Total Score:

Language Result:

Language Total Score:

Social-Emotional Result:

Social-Emotional Total Score:

Adaptive Result:

Adaptive Total Score:

Age: 25–36.9 Months
Grade: Nursery

Instructions: Read each statement carefully and select the answer that best describes your child’s behavior during the last 30 days.

Cognitive: Can your child complete a simple puzzle (e.g., 3–4 pieces)?

Cognitive: Does your child match similar objects (e.g., shoes, animals)?

Motor: Can your child jump with both feet?

Motor: Can your child draw a line or circle?

Language: Can your child form 2- to 3-word phrases (e.g., “want juice”)?

Language: Does your child ask simple questions like “What’s that?”

Social-Emotional: Does your child play pretend (e.g., feeding a doll)?

Social-Emotional: Does your child show awareness of other people’s feelings?

Adaptive: Can your child take off some clothes without help?

Adaptive: Is your child starting to show interest in potty training?

Cognitive Result (Nursery):

Cognitive Total Score (Nursery):

Motor Result (Nursery):

Motor Total Score (Nursery):

Language Result (Nursery):

Language Total Score (Nursery):

Social-Emotional Result (Nursery):

Social-Emotional Total Score (Nursery):

Adaptive Result (Nursery):

Adaptive Total Score (Nursery):

Age: 37 – 60 Months
Grade: Kindergarten 1 & 2

Instructions: Read each statement carefully and select the answer that best describes your child’s behavior during the last 30 days.

Cognitive: Can your child count to 5 or recognize some colors?

Cognitive: Can your child follow two-step directions (e.g., “Get your shoes and put them by the door”)?

Motor: Can your child hop on one foot or catch a large ball?

Motor: Can your child use scissors to cut paper?

Language: Can your child tell a short story or describe an object?

Language: Are you able to understand what your child is saying most of the time?

Social-Emotional: Does your child play cooperatively with other children?

Social-Emotional: Does your child express emotions appropriately (e.g., anger, frustration)?

Adaptive: Can your child dress and undress without help?

Adaptive: Can your child use the toilet independently?

Cognitive Result (Kindergarten):

Cognitive Total Score (Kindergarten):

Motor Result (Kindergarten):

Motor Total Score (Kindergarten):

Language Result (Kindergarten):

Language Total Score (Kindergarten):

Social-Emotional Result (Kindergarten):

Social-Emotional Total Score (Kindergarten):

Adaptive Result (Kindergarten):

Adaptive Total Score (Kindergarten):

SOCIAL EMOTIONAL BEHAVIORAL SCREENING

Age: 24 – 60 Months
Grade: Play Group – KG 2

Instructions: Read each statement carefully and select the answer that best describes your child’s behavior during the last 30 days.

Complains of aches or pains (e.g., stomach, head) without clear cause

Seems sad, unhappy, or cries easily

Seems irritable or angry more than usual

Has trouble sitting still or staying in one place

Is easily distracted or has trouble focusing on tasks or play

Doesn’t listen when spoken to directly

Fidgets with hands or feet or squirms in seat

Acts as if “driven by a motor” or always “on the go”

Argues or talks back when told to do something

Has difficulty waiting for their turn

Blames others for their mistakes

Hits, kicks, or bites others when upset

Seems anxious or worries a lot

Is afraid to try new things or explore surroundings

Refuses to separate from parents or caregivers (e.g., at school/daycare)

Has nightmares or trouble sleeping

Loses temper easily or has frequent tantrums

Internalizing Score

Attention Score

Externalizing Total Score:

Externalizing Score

Attention Total Score:

Internalizing Total Score:

AUTISM SPECTRUM DISORDER SCREENING

Age: 24 – 60 Months
Grade: Play Group – KG 2

Please answer the following questions about your child’s typical behavior over the past 3 months.

Does your child make eye contact when talking or playing?

Does your child show feelings like happiness, sadness, or anger in ways you understand?

Does your child use gestures like pointing, waving, or nodding to communicate?

Does your child gets upset to changes in routine or new situations?

Does your child respond when someone calls their name or speaks to them?

Does your child use words or sentences to express needs or feelings?

Does your child use facial expressions (smiling, frowning) to communicate?

Does your child seem more restless or less active than other children?

Can your child follow simple directions (e.g., “Bring me the toy”)?

Does your child play with other children or engage in group activities?

Autism Spectrum Score

Autism Spectrum Total Score:

AUTISM SPECTRUM

PRIMARY/SECONDARY PSYCHOLOGICAL SCREENER

Age: 6-16 years
Grade: 1-10

Instructions: Ask the child: "In the past few weeks, how often have these things been true for you?"
Ask each question in a child-friendly, age-appropriate way. Mark the response as reported by the child.

You feel sad, unhappy, or like crying.

You are easily distracted or have trouble concentrating.

You feel nervous, worried, or afraid a lot.

You have trouble sleeping or feel tired most of the time.

You feel lonely or like being alone more than usual.

You often argue or talk back when told to do something.

You take things that do not belong to you or refuse to share.

You fight with other children or get angry quickly.

You don’t enjoy things you used to enjoy.

You are clingy or need to be with adults all the time.

You have trouble sitting still or feel “on the go” a lot.

You don’t listen to rules or directions.

Internalizing Result

Internalizing Total Score:

Externalizing Result

Externalizing Total Score:

Attention Result

Attention Total Score:

Psychological Assessment Comments:

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Nutritionist

Question No.60: How would you describe your lifestyle?

Question No.61: BMI

Question No.62: MUAC

Question No.63: Daily Protien requirement

Question No.64: Daily Energy
requirement

Question No.65: How many glasses of water/liquids do you consume in a day?

Question No.66: Does the child have any history of substances abuse or addiction to

Question No.67: Does the child suffer from any food intolerances/ food allergies?

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Question No.68: How would you describe your
lifestyle?

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Question No.69: How many meals (breakfast / lunch / dinner) do you consume in a day?

Question No.70: How many packed items/foods (chips / biscuits sodas) do you consume in average in a day?

Question No.71: How frequently do you consume fast food on dineout on average in a week?

Comment

Follow-up Required

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DURATION

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For Wasting criteria from Birth to 5 years Girls

For Wasting criteria from Birth to 5 years Boys

For children and adolescents(Girls) Wasting (Criteria 5-19)

For children and adolescents(Boys) Wasting (Criteria 5-19)

STUNTING CRITERIA: FOR BIRTH TO 2 YEARS Girls

STUNTING CRITERIA: FOR BIRTH TO 2 YEARS Boys

STUNTING CRITERIA: FOR 2 TO 5 YEARS Girls

STUNTING CRITERIA: FOR 2 TO 5 YEARS Boys

STUNTING CRITERIA: FOR 5 TO 19 YEARS Girls

STUNTING CRITERIA: FOR 5 TO 19 YEARS Boys

DIETERY COMMENT

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DOCTOR COMMENT

Screening Detail

Bio Data

Name : {{ $details['name'] }}

Date Of Birth : {{ $details['dob'] }}

Age :

Class : {{ $classLabels[$details['class']] ?? $details['class'] }}

GR Number : {{ $details['gr_number'] }}

MR Number : {{ $details['mrr'] }}

Guardian Name : {{ $details['guardianname'] }}

Address : {{ $details['address'] }}

Blood Group : {{ $details['blood_group'] }}

Gender : {{ $details['gender'] }}

Vitals/BMI

General Apperance

Inspect Hygiene

Head and Neck examination

Eye:

Ears:

Nose:

Lead Exposure

Oral:

Throat:

Chest:

Abdomen:

Musculoskeletal

Vaccination:

Lead exposure

Miscellaneous

Psychological

PRE-PRIMARY PSYCHOLOGICAL SCREENER

DEVELOPMENTAL SCREENING

SOCIAL EMOTIONAL BEHAVIORAL SCREENING

AUTISM SPECTRUM DISORDER SCREENING

PRIMARY/SECONDARY PSYCHOLOGICAL SCREENER

Nutritionist