Proyash Institute of Special Education
Preassessment of Child
1. Child Information
Child Full Name
Date of Birth
Place of Birth
Age (years)
Gender
Select Gender
Male
Female
Other
Blood Group
Height (cm)
Weight (kg)
Birth Registration Number
Identification Mark
School Name
Present Address
Permanent Address
Guardian Name
Guardian Phone Number
Emergency Contact Person Name
Emergency Contact Phone Number
Emergency Contact Address
Previous Medicine (if any)
Referred By
Next
2. Parents Information
Father Information
Father Name
Father Age
Father Education
Father Occupation
Father Contact Number
Father Habit
Father Health Conditions
Heart Disease
High Bp
Low Bp
Hypothyroid
Hyperthyroid
Diabetes
Asthma
Other Medical Abnormality (Father)
Mother Information
Mother Name
Mother Age
Mother Education
Mother Occupation
Mother Contact Number
Mother Habit
Mother Health Conditions
Heart Disease
High Bp
Low Bp
Hypothyroid
Hyperthyroid
Diabetes
Asthma
Other Medical Abnormality (Mother)
Previous
Next
Siblings Information
Sibling Name
Gender
Select
Male
Female
Other
Age
Remarks
+ Add Another Sibling
Previous
Next
3. Family History
Parents Marital Status
Select status
Living Together
Divorced
Widowed
Living Separately
Consanguineous Marriage (Blood relation)
If Yes, Relationship Type
Select relation
First Cousin
Second Cousin
Other
Family Type
Select family type
Nuclear
Joint
Other
Father Age at Marriage
Mother Age at Marriage
Previous
Next
4. Pregnancy & Delivery History
Mother Age During Pregnancy
Illness During Pregnancy
Pregnancy Related Problems
Pregnancy Problem
Stress Or Injury
Abortion History
Medicine First Trimester
Xray Ct Mri
Place of Delivery
Home
Hospital
Clinic
Other
Delivery Type
Normal
Caesarean
Instrumental
Baby Type
Single
Twin
Other
Labour Complication
None
Prolonged
PROM
Difficult
Baby Position
Head down
Breech
Other
Pregnancy Duration
Full Term
Preterm
Post-term
Baby Cry Time After Birth
Birth Weight (kg)
Complications During Delivery
Oxygen Lack
Breathing Support
Medicine Given
Injury During Delivery
Previous
Next
5. Health & Development
Post Natal Disease Name
Age When Disease Occurred
Child Had This Disease
Child Has Seizure
Type of Seizure
Select
Febrile
Whole Body
Part of Body
Seizure Medicine
Seizure Related History
Infantile Spasm
Seizure Controlled
Severe Seizure History
Thyroid Condition
Normal
Enlarged
Developmental Observation
Movements Normal
Complications
Father Support
Developmental Notes
Previous
Next
6. Services Taken & Present Problems
Services Taken by Child
Medical Treatment
Investigations
Therapy
School Attending
Special Education
Main Presenting Problem
Problem Type
Behavioural Problem
Physical Problem
Learning Difficulty
Other Abnormality
Previous
Next
7. Vaccination History
BCG
Vaccine Taken
Age at Vaccination
OPV / Polio
Vaccine Taken
Age at Vaccination
Pentavalent
Vaccine Taken
Age at Vaccination
PCV
Vaccine Taken
Age at Vaccination
IPV
Vaccine Taken
Age at Vaccination
MR (Measles-Rubella)
Vaccine Taken
Age at Vaccination
COVID-19
Vaccine Taken
Age at Vaccination
Other
Vaccine Taken
Age at Vaccination
Previous
Submit Pre-Assessment