Early Detection & Intervention
Baby Registration Form
Parents & Personal Information
Parent's Phone Number *
Baby Name *
Father Name *
Mother Name *
Baby's Birth Date *
Health & Siblings Information
Gender *
Select Gender
Male
Female
Blood Group *
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Birth Weight (kg) *
Current Weight (kg) *
Length/Height (cm) *
Head Circumference at Birth (cm) *
No. of Siblings *
Address & Contact Information
Address *
District *
Taluka *
Select Taluka
Karjat
Rahata
Shrigonda
Talathi *
Village *
Grampanchayat *
PHC *
Screening & Examination Status
Status of OAE Test for Hearing *
Select Status
Done
Not Done
Status of Universal Eye Screening/ROP *
Select Status
Done
Not Done
Delivery & Complications Information
Type Of Parent's Marriage *
Select Type
Consanguineous
Non-Consanguineous
Type Of Delivery *
Select Type
Normal (vaginal) delivery
Lower segment cesarean section
Prenatal Complications
Infections
Exposure to Toxins
Developmental Malformation
Maternal Age
Maternal Disease
Perinatal Complications
Low Birth Weight
Prematurity
Obstetric Complications
Trauma During Labour
Asphyxia
Intracranial Haemorrhage
Postnatal Complications
Jaundice
Sepsis
Congenital Heart Disease
Surgical Complications
Respiratory Distress
Malnutrition
Poisoning
Tumors
Environmental Factors
Psycho-social Problem
Ongoing & Past Medications Information
Previous Treatment Taken *
Current Treatment Taken *
Current Medications (If any) *
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