Child Entry Form

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Child Name:   __________________________________            Date of Birth:  _________________

Male  ___         Female     ___                                                      Today’s date:  _________________

Parent Name and Full address:   ___________________            ID number:      _________________

_____________________________________________

_____________________________________________

Father’s employment & income:

_____________________________________________

 

1.     Date of identification: _____________                                [take from RBSK referral form]  

2.     Child’s main diagnosis:_________________________________________________________

3.     Other diagnoses: _____________________________________________________________

_______________________________________________________________________________              

4.     Does the child receive any treatment or therapy? ___________________________________

5.     Does the child take any medication regularly? ______________________________________

6.     Tell me the names and ages of all who live in the house. (Note in relationship to child)   

 

                            Name                                    Relationship to child       Age              Education

1.          ____________________________              Father                      ____        _________________

2.         ____________________________               Mother                     ____        _________________

3.         ____________________________  __________________         ____        _________________

4.         ____________________________  __________________         ____        _________________

5.         ____________________________  __________________         ____        _________________

6.         ____________________________  __________________         ____        _________________

 

7. Birth History

 

 

 

8. Early milestones and development

 

 

9. Who are the people in the family who bathe, feed and care for the child most often? 

 

 

10. Primary concerns and priorities of the family

 

 

11. Describe the child’s routine from the time they wake up until the end of the day. Please record all activities and details of routines such as length of sleep, and details of meals.

 

 

 

 

12. Describe the routine of the primary caregiver/s.

 

 

 

 

13. List all who regularly interact, play with and spend time with the child (family members, neighbours)

 

 

 

14. Is there anyone or any organization in your village/ community who supports you in caring for your child? [eg. Anganwadi, local teacher, local health worker etc. )

 

 

15. How would you come to this center? How long does it take?

 

 

Based on the information gathered and your assessment of child needs, please note the recommendation for service including where and how often the services will be provided.

Recommendation:

 

 

 

 

 

 

Download this form as a word document.