Sujay Child Development Centre - Multilingual Parent Intake

1. Child Identification & Family Details

Preschool Track (<6y)

Child's Full Name *

Gender *

Male

Female

Date of Birth *

Age Display

Hand Preference

Right

Left

Shifting / Both

WhatsApp Contact Number *

School Name & Current Class

2. Caregiver Primary Concerns (Tap all that apply)

Sitting, Energy Level & Motor Control

Cannot sit still in one place (Ek jagah baithta nahi hai, climbs tables/sofas)

Always on the go / Runs fearlessly into road or traffic

Shifts toys within 30-60 seconds; leaves games scattered

Excessively passive / Floppy body posture (Bohot dheela lagta hai)

Speech, Name Call, Eye Contact & Social Play

Does not respond to name call (Naam lene par dekhta nahi)

Hand-leading (Ungli se nahi dikhata, haath kheench kar le jata hai)

Fleeting or absent eye contact during interactions

Solitary play; ignores other children (Dusre bacchon me mix nahi hota)

Repetitive play: lines up toys in rows or fixated on spinning wheels

Repeats cartoon dialogues or questions repeatedly (Echolalia)

Sensory Reactions & Meltdowns

Haircut, nail cutting or head-wash screaming battles

Irritation with clothing tags, tight collars, or sock seams

Covers ears / panics at mixer-grinder or pressure cooker sounds

Avoids messy play: refuses to touch clay, mud, paint, or slime

Crashes into furniture, jumps non-stop, chews clothes or toys

Prolonged 30-45 minute inconsolable tantrums over small changes

Eating, Balance & Clumsiness

Refuses solid food; gags on chapatis/rice; takes purees/milk only

Pockets food in cheeks for 20-30 minutes without chewing

Persistent toe-walking (Panjo par chalna)

Frequent falls, trips on plain ground, bumps into doorframes

W-sitting position on floor (Cannot sit cross-legged)

Caregiver Observations in Own Words

3. Birth & Medical Background

Mode of Conception

Natural / Spontaneous

IVF

IUI / Induction

Mode of Delivery

Normal Vaginal

Elective LSCS (C-Section)

Emergency LSCS

Forceps / Vacuum

Birth Cry & Respiration

Immediate Vigorous Cry

Delayed Cry (Stimulation needed)

NICU Stay / Resuscitated

4. Developmental Milestones & Daily Skills

Independent Sitting (Expected: 6-8 months)

Sat independently on time (6-8m)

Delayed (After 9-10 months)

Sits in 'W' shape on floor (Cannot sit cross-legged)

Hands-and-Knees Crawling (Expected: 8-10 months)

Crawled on hands and knees on time

Skipped crawling completely (Direct to standing)

Bottom shuffled on floor / Delayed

Independent Walking (Expected: 12-15 months)

Walked on time with feet flat

Delayed walking (After 16-18 months)

Persistent toe-walking (Panjo par chalna)

Stairs & Jumping (Expected: 2.5 - 3.5 years)

Climbs stairs alternating feet & jumps with both feet

Two feet per step on stairs / Relies on railing

Fearful of jumping / Cannot clear floor with both feet

Drawing, Shapes & Scissors (Expected: 3 - 4 years)

Copies shapes (| — ○ +) & snips paper with scissors

Vigorous scribbling only; cannot imitate shapes

Avoids scissors / Tears paper with two hands

Self-Feeding Autonomy (Expected: 15-18 months)

Eats independently with spoon with little spillage

Finger feeds only / Messy food spillage

100% adult hand-fed for all meals

Toilet Training (Expected: 2.5 - 4 years)

Fully trained for day and night toilet

Day trained only / Night bedwetting

Diaper dependent / Fears commode or flushing sound

5. Sensory Profile & Everyday Reactions

1. Tactile Processing (Touch Tolerance)

0 - Typical tactile tolerance

1 - Dislikes tags, sticky hands, or socks

2 - Severe haircut/nail screams OR craves rough textures

2. Vestibular Processing (Movement & Balance)

0 - Typical movement tolerance

1 - Cautious on swings OR seeks extra rocking

2 - Fear of feet leaving floor OR non-stop spinning

3. Proprioception (Force Grading & Pressure)

0 - Calibrates pressure appropriately

1 - Rough play, stomps feet, presses hard on pencils

2 - Constant crashing, jumping, breaks toys, bites items

4. Auditory Processing (Sound Filtering)

0 - Filters background ambient sound

1 - Easily distracted by appliance hums / noise

2 - Covers ears at mixer/cooker OR ignores speech

5. Oral Sensory & Eating Behavior

Eats all family foods smoothly

Picky eater: purees or dry crunchy snacks only

Gags on lumps / Pockets food / Chews shirt collar

6. Activities of Daily Living (ADLs)

Self-Feeding Independence

0 - Independent with spoon and cup

1 - High food spillage, finger feeds only

2 - Dependent; must be fed by parent

Dressing Participation & Fasteners

0 - Independent with buttons & zippers

1 - Slow with small buttons, zipper struggles

2 - Fully adult-dependent for clothing

Sleep Habits & Settling

Falls asleep easily, sound overnight sleep

Resists bedtime, needs prolonged soothing/screens

Frequent night awakenings / Restless sleep

7. Fine Motor, Handwriting & Attention

Pencil Grasp Maturity

0 - Dynamic tripod grasp (fingertip control)

1 - Closed web space / thumb wrap / hooked wrist

2 - Immature fist grasp; moves from shoulder

Pencil Pressure & Muscle Fatigue

0 - Optimal pressure; writes 15+ mins without pain

1 - Heavy pressure (tears page) or faint strokes

2 - Hand cramps, shaking, refuses to write in <5 mins

Sustained Tabletop Attention

0 - Focuses 15-20+ minutes independently

1 - Sustains 5-10 mins then drifts / fidgets

2 - Abandons desk or loses focus in <2-3 mins

Response to Name Call

0 - Turns head immediately within 1-2 calls

1 - Responds only when offered food or screen

2 - Acts as if hard of hearing / does not orient