Full Name *
Age *
Father's Name *
Village *
City *
District *
State * Select an option…Andhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJammu and KashmirJharkhandKarnatakaKeralaLadakhMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest BengalAndaman and Nicobar IslandsChandigarhDadra and Nagar HaveliDaman and DiuDelhiLakshadeepPondicherry (Puducherry)
Contat Number (optional)
Email *
Occupation (of parent/guardian) *
Child Cried at Birth *Cry No Cry
Type of Delivery *Normal Operation
Gestation Period *7 Months8 Months9 MonthsLate
NICU Required *YesNo
CURRENT PROBLEMS (if any) *
Sitting *Yes No
Standing *YesNo
Walking *YesNo
Speech *YesNo
Drinking *YesNo
Catching *YesNo
Eating *YesNo
Push-Pull Actions *YesNo
Work Capability: Can perform tasks properly *YesNo
Medication: Currently on any drugs *Running Not Running
Surgical History: Any part operation: *YesNo
Order notes (optional)
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