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DEVELOPMENTAL DELAYS QUESTIONNAIRE

Parent’s Name:- .Mr.NISHITH SACHAN & Mrs.ANJULA SACHAN

Child Name:- Master ADVIK SINGH Age:- 5.5+ Yrs , MALE Child

Phone No.:- 9583040638

Email Id : nsachan01@gmail.com

Immunity Assessment
During the first year, did your child fall ill more often and was considered sickly?
NO.The child was more or less healthy but frequent cough & cold was the comman
problem.
Did your child have constipation/diarrhea problems?
NO Constipation.Upto the age of approx. 3 yrs the child had three to four motions in a
day but once in while the child had loose motions / diarrhea which was treated through
allopathic medication.
Did your child take long to recover from cold, coughs or fever?
NO.Recovery was within 3 or 4 days.
Did you notice behavior changes and a reduction in cognitive / intellectual functions
following MMR vaccination?
NO permanent behavior changes / reduction in cognitive or intellectual function was
observed after MMR vaccination, however within half an hour after giving MMR
vaccination the child had fits once and fainted for nearly 5 to 10 mins.There after he had
fever with shivering which got cured in couple of days.
How many days after the vaccination did the symptoms appear?
As mentioned above after the fits the child only had fever for approx. two days but all his
activities and behaviors were as before.
At present, does your child have constipation or diarrhea often?
NO.
Does your child suffer from bronchial or asthma?
NO.

Cognitive, Intellectual Function
How would you score your child's language skills? 0-5 (5 being Highest)
1 on the scale of 0-5.However the child speak much more with his mother than his
friends.
Does the child pick up words and phrases easily?
NO.However the child picks up words or phrases used by his mother quickly but so is
not the case with friends.
Does the child use the words in context or out of context?
Uses the words in context.
Is the child capable of putting words into sentences?
Almost NO but can repeat sentences after recitation / hearing.
Does the child repeat words or phrases when he/she is not expected to? (out of context)
NO.

Is your child mathematical? Does he/she show more capability with numbers than
words?
Child can be said bit mathematical as since long he showed interest in arranging the
similar / dis-similar objects in line / one above another and counting them numerically.

Does your child show any artistic, creative interest, skill?
YES.The child is always interested in sketching something, colouring the same, cutting
the page and sometimes sticking it on the wall etc.


Emotional Assessment
Does the child show affection easily?
YES.The frequency of exhibiting affection is more with younger children than the elder
ones / elderly people.
How does the child show affection? Please describe
The child shows affection by hugging.However with infants he shows affection by
touching the cheeks and hands etc.
Does the child cry when you are upset or angry with him/her?
YES.
Does the child throw tantrums easily?
YES
Which emotions does the child show easily? (love,affection,anger,jealousy etc)
Anger and jealousy.
Does the child share his/her toys and playthings with others?
YES but often it is like exchanging toys.
Does the child approach strangers and hug?
NO but once the child has developed friendship he may hug.
Does the child show aggressive behavior such as pushing or shoving other children in
class or play area?
NO.The aggressive behavior is absent in normal course, however if the person teases
him he becomes aggressive and starts pushing or shoving that person.

Behavioral Concerns
Does the child babble or utter sounds that do not have meaning?
NO but often imitates certain cartoon characters by making sounds during playing.
Does the child walk on toes?, how often?
NO.
What kind of behaviors does the child show?
ANGER, HAPPINESS,SADNESS,EXCITEMENT,CALM &
QUITENESS,DISCIPLINE,MANNERS,HOSPITALITY to GUEST

Does the child show any peculiar eye or hand movements? Please describe
Nothing specific, but child shows some kind
Nothing specific, but gives varied expressions with his eyes.
Does the child show greater sensitivity to: Light, sound, touch
LIGHT – Lights attract him and particularly prefers to be close to and play in colourful
light.
SOUND – Child is afraid of and run away by strong sounds like cooker whistle, sound
of mixer grinder.Also upto three years of age he used to cry a lot because of the sound
of diwali crackers etc.
TOUCH – Sensitive to touch.Does not like that people should touch his face or hand.If
someone touches him he reppells.Also doesnot like his head to be touched particularly
combing his hairs is tough task.
Does the child sing? If YES, are the words or he/she is making musical sounds without
words?
YES he sings rarely but the singing is with words.The words are not very clear rather
they are mixed / mingled with each other and what comes out to the listener is mix of
words and music tones.

Motor Skills
Can your child use a pen or a pencil properly?
YES the grip is proper but avoids to write.He gets uncomfortable in pressing the pencil
with fingers and writing on the paper systematically.Rather he is interested in using the
pencil at random making lines , random figures , circles etc.
Does your child use a fork or a spoon when he/she eats?
YES he uses both.
How would you rate your child's drawing capabilities? 0-5 (5 being Highest)
1 out of 5.He is only interested in clouring the objects.
Does your child have any problems chewing food?
NO not now. But during his earlier years he avoided chewing hard food.He used to spit
out any hard food given to him


Command And Communication
Does your child respond when his/her name is called out?
YES.
When given a simple instruction to do something, does your child agree to do it but
forgets the instruction to do it?
YES he follows instructions but after repeating many times.
If your child is told to go and bring something from a different room, can he/she go to
the room and bring the requested item?
YES he can but gets only those things which are of his interest.Say he can get a plate
/a knife but he will not get masala / flour etc.



Sleep
What time does your child fall asleep at night?
Generally between 10.00 to 11.00 PM.But making him sleep takes long time.
Does he or she wake up during the night more than once?
NO.
If wakes up, how long does it take for him/her to fall asleep again?
------
Does he or she sleep during the day?
YES around 3.00 PM in afternoon.

What is the total number of hours does he/she sleep in a day?
Total approx 10 hrs a day.
Is he/she angry, irritable or upset when woken up from sleep in the morning?
YES he gets irritated when woken up, but if he gets up all by himself he is calm and
quite.

Toilet training
Does your child use the toilet to pass urine and stool?
YES.

Pain Sensitivity
Does your child cry out immediately if he/he hurts himself?
YES.
Do you think that your child experiences physical pain as normally or do you feel he is
strong and does not feel pain easily?
Child experiences pain normally.





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560 043
Phone : +91 80 2545 8516 Visit : www.xyclinics.com