NAME OF CHILD
DATE OF BIRTH
SEX MaleFemaleOther
TEL. NO.
FATHER NAME
OCCUPATION
EDUCATION
INCOME
MOTHERS NAME
MOTHER TONGUE
RELIGION
OTHER LANGUAGES SPOKEN
ADDRESS
AGE OF SITTING
STANDING
WALKING
Any history of convulsions, Brain, Fever,Rickets,Injury,Fall,Paralysis any illness during Birth/Infancy
Behavioral issues if any
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