Assessment Performa: 1. Father: a. Name: b. Age: c. Language Known: d. Education Level: Illiterate <Secondary School Secondary School Sr.

Secondary School Graduate Post Graduate e. Have any cognitive, visual or intellectual impairments (if yes mention) ____________________________

2. Mother: a. Name: b. Age: c. Language Known: d. Education Level: Illiterate <Secondary School Secondary School Sr. Secondary School Graduate Post Graduate e. Have any cognitive, visual or intellectual impairments (if yes mention) ____________________________ 3. Adolescent: a. Name: b. Date of Birth: c. Age: _____ Years _____ Months. d. Gender : e. Class: f. School/College: g. Language Known:

4. Family structure: __________________________________ 2-parent family Single-parent family Joint Family Other family (Institutionalized Facility or Group Homes)

Family Income per Month: _______________________________ Up to Rs.20 000 Rs.20 000 Rs.45 000 Rs.45 000 Rs.75 000 Rs.75 000 Above Imputed a) Is your ward diagnosed with any of the following: Cognitive Impairments. Neurological Condition. Genetic Syndrome. Motor Disorders. Trauma- Bony/ Soft Tissue Injuries. Major Medical Illness Intellectual Disability.

b) Is ward is Blind/Deaf /Dumb(if yes mention)__________ (To be filled by Researcher only) Height Weight Body Mass Index

HRQOL (PedsQLTM 4.0 Score) Teen Report Parent Proxy

Physical

Emotional

Social

School

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