SUJAY CHILD DEVELOPMENT CENTRE

Complete Pediatric Occupational Therapy Intake Portal
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SUJAY
CHILD DEVELOPMENT CENTRE
“Enabling and enhancing child potential and performances”
102, 1st Floor, Bangshree Tower, Opp. Pawar Ind. Estate & SBI ATM, Daji Ramchandra Rd, Charai, Thane (W) - 400601
Consultant: Dr. Chirag J. Gandhi (Occupational Therapist) | Mob: 9136801368 / 9930785101
1. Child Identification & Family Details Demographics
Male
Female
Right
Left
Shifting / Both
2. Detailed Checklist of Child Concerns Tap All That Apply

All categories are open so you can select your child's exact difficulties regardless of age. Tap on every statement that matches your child's daily habits:

A. Physical Movement, Balance & Body Coordination
Clumsiness: Frequent tripping, falling over feet, or bumping into furniture/doors
Persistent toe-walking: Walks on tiptoes instead of placing heel flat on floor
Weak core stability: Slumps at the desk, rests head on arm or table while sitting
Stairs difficulty: Still places both feet on each step; needs to hold railing tightly
Ball games avoidance: Struggles to throw with direction, cannot catch, or flinches/closes eyes
Bicycle balance: Cannot ride a 2-wheel bicycle without training wheels; poor balance
B. Fine Motor, Pencil Grasp & Handwriting Biomechanics
Awkward pencil grasp: Uses a tight fist, wraps thumb tightly, or hooks wrist awkwardly
Hand cramping & fatigue: Shakes hand, complains of finger pain after 5-10 mins of writing
Slow writing pace: Cannot finish copying from blackboard in class; leaves exam sheets blank
Extreme pencil pressure: Presses so hard the paper tears/dents OR writes extremely faint
Spatial messiness: Letters float above the line, words collide together without spaces
Letter/Number reversals: Persistently reverses b/d, p/q, or numbers (2, 3, 5, 7)
Scissors & craft struggles: Struggles to cut forward along lines or tear paper neatly
C. Sensory Reactions (Touch, Movement, Sounds & Textures)
Grooming meltdowns: Screams or panics during haircuts, nail clipping, or face washing
Clothing tactile distress: Refuses tight clothes, clothing tags, sock seams, or jeans
Sound sensitivity: Covers ears or screams at mixer, pressure cooker, crackers, or blenders
Intense movement craving: Spins in circles non-stop, rocks body, jumps off furniture without dizziness
Fear of movement: Panics on swings, heights, or when feet leave the ground
Rough crashing & body slamming: Throws self onto floor/sofas, tackles peers, stomps feet heavily
Object chewing: Constantly chews shirt collar, sleeves, pencil ends, or non-food items
High pain tolerance: Does not cry or flinch on cuts, bruises, or injections
D. Attention, Arousal Levels & Impulse Control
Restless hyperactivity: Constantly on the move as if driven by a motor; cannot sit for meals
Short seated attention: Leaves study chair or loses focus within 2-3 minutes
High distractibility: Easily pulled away by ambient sounds, people talking, or window views
Impulsivity & lack of danger awareness: Runs onto roads, climbs high ledges without caution
Forgetful & disorganized: Regularly forgets school diary, pencil box, water bottle, or books
Daily homework battles: Extreme resistance, crying, or takes 3 hours for 15-minute homework
E. Social Engagement, Play & Emotional Flexibility
Inconsistent name response: Does not turn head when called; acts as if hard of hearing
Fleeting eye contact: Avoids direct eye gaze; looks only when asking for food/screens
Mechanical hand-leading: Takes adult's wrist to reach snacks instead of pointing or speaking
Repetitive toy routines: Lines up cars/blocks in rows, spins wheels, or opens/closes doors obsessively
Difficulty playing with peers: Prefers solitary play, grabs toys without asking, or avoids groups
Rigid transitions: Severe crying or tantrums if travel route changes or routines are interrupted
Physical aggression: Hits, bites, pinches, or pushes when excited, overwhelmed, or denied
F. Feeding, Diet & Mealtime Habits
Severe food refusal / Picky eating: Restricted to fewer than 5-10 specific foods
Gags on textures: Gags or throws up when eating rice lumps, vegetables, or whole fruits
Requires liquid/puree consistency: Refuses chewing crunchy or chewy solid foods
Pocketing food: Keeps food inside cheek without swallowing for 30+ minutes
Mealtime dependence: Parents must hand-feed every bite or child will not eat
G. Self-Care, Dressing, Fasteners & Hygiene
Fastener dependency: Cannot manage small uniform buttons, pant hooks, or zippers
Shoelace struggles: Cannot tie shoelace bows; requires Velcro or slip-ons
Backward clothing: Puts shoes, socks, or pants on backwards; struggles with orientation
Bathing & tooth brushing distress: Major battle to wash body, rinse shampoo, or brush teeth
Daytime toilet accidents: Forgets to use toilet; wets or soils pants during day
Restless bedtime sleep: Takes 1-2 hours to sleep; tosses restlessly or wakes screaming
3. Conception, Delivery & Medical Background Medical History
Natural / Spontaneous
IVF
IUI / Ovulation Induction
None / Normal
Gestational Diabetes
High Blood Pressure (Preeclampsia)
Thyroid Disorder
Strict Bedrest / Bleeding
Normal Vaginal
Planned LSCS
Emergency LSCS
Forceps / Vacuum
Immediate Vigorous Cry
Delayed Cry (1-3 min, back rub)
Severely Delayed (>3 min, required oxygen)
Intubated / Ventilator
Normal (2.5 - 3.5 kg)
Low (<2.5 kg)
Very Low (<1.8 kg)
No NICU (Kept with Mother)
Observation (<48 hrs)
Phototherapy (Jaundice)
Prolonged NICU (>7 days)
Strong suck / Breastfed well
Weak suck / Tired quickly while nursing
Frequent milk choking / milk from nose
Required tube feed (NG Tube)
No Seizures
Fever Fits (Febrile)
Epilepsy (On Meds)
Non-Consanguineous
Related (Family Marriage)
4. Early Movement & Motor Milestones Milestone Ages
On Time (3-4m)
Delayed (5-7m)
Significantly Delayed (>7m)
On Time (6-8m)
Delayed (9-11m)
Persistent W-Sitting on floor
Crawled on time on hands & knees
Skipped crawling directly to walking
Delayed / Bottom-shuffled
On Time (12-15m)
Delayed (>16 months)
Walks on tiptoes frequently
On Time (Mamma, Pappa, etc.)
Delayed (>18 months)
Not yet speaking clear words
No: Skills developed steadily without loss
Yes: Lost eye contact, words, or social gestures between 15-24 months
5. Daily Habits & School Feedback Environment
< 30 minutes
1 - 2 hours
> 3 hours daily
Active / Plays with peers
Watches peers / Hesitant
Avoids playground / Prefers screens