Childhood Information: Parents should fill in this Questionnaire (survey):
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Mention any remarkable incidences, any repetitive recurrences of physical / mental ailment, which you think, might have affected the psyche of the child (in short)

Does the child display either of the ADHD or Inattentiveness symptoms? 
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Do you believe that the child might have shocked, because of physical or sexual abuse and is hiding that fact from parents?
Yes No I Can't Tell

Is the child is adopted one? Yes No
If "Yes" then while adopted, age of child was Yrs

Is there a bedwetting tendency occurs in this child? Yes  No  Sometimes

If you mark 'Yes' OR 'Sometimes' for bedwetting, them probable its reasons may be?
Fearful Nature Nightmares Insecurity  Hereditary Reasons 
Kidney or Bladder problems Moving to a new environment 
Losing a family member or loved one Arrival of a new baby or child in the home
One of the parent or family member is very strict. Fear of punishment 
Odd or irregular habits (-like habits of passing stool or Taking sleep or meals) 
Shocked psyche

Do you think that any traumatic life event like death of nearer or separation of parents might have influenced the psyche of the child?
Yes No May Be, I can't tell

Have you observed some of the learning problems like LD in the child? Click Appropriate to Check Learning Disabilities and General Student Negativities. 
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School going behavior of the child is?
Exciting or enjoyable event. Brings fear or panic
Feels sick OR "plays sick" Find multiple excuses to avoid school 

General nature of child is:
Hyperactive and Impatient Changing frequent moods 
Calm and Quiet Eccentric Nature sometimes gets violent, angry, or vengeful

Do you think that the child has got some of the negativities mentioned below?
Envious / Hateful Nature Pessimistic approach towards life
Guilty, self-reproaching or self-punishing tendencies 
Doesn't like to share his or her problems Drastic mood swings Depressed 
Irritable and demanding Tendency to blame others for his or her problems

This child was Delivered  Normal Prematurely ORLate than Normal (15-30 Days)

This child is:
Vulnerable and easily prone to general diseases
Having good resistivity as far as the diseases are concerned
Mediocre resistivity, can't say specific about it

Does the child is being reared in day care? Yes No
If yes then since the age N.A. 1 2 3 4 5 6 7 8 9 10 11 12

Do you believe that the child may be a victim of physical or verbal bullying?
NA Yes No May be, I can't tell 

General nature of child is:  
Normal Dominating Submissive / Vulnerable to bullies

Physical posture of child is?
Normal Slightly Obese Weak than normal

Does the child easily prone to general diseases (e.g. fever, cold etc) even on the slightest alternation in the surrounding weather conditions?
Yes No

Does the child is on health tonic or capsules for improving physical health?
Yes No 

How is the nature of his or her sleep?
Sound Sleep Often wakes up crying, may be due to dreams, nightmares etc.
Sleeplessness, Insomnia

Does the child like to mingle with the company / friends?
Always Occasionally Never

Do you find that, the child often shows drastic mood swings such as joy and sadness, energy and apathy, optimism and pessimism in his/her every day routine?
Yes No Sometimes, recurring tendencies of drastic mood swings

Does the child gets nervous / irritated over trivial issues?
Yes No

Does the child often feels drowsy or lethargic and sleeps heavily and don't want to get out of bed?  
Yes No  Sometimes

Does the child ever feel enraged and feared of losing control with violent impulses and sometimes afraid of hurting itself or others?  
Yes No

Does the child suffer from nightmares?  
Yes No May be

Does the child seems to be having suicidal tendencies?  
Yes No May be, I can't tell

Usually, the mind of child remains?
Stable Dwindling between stable & unstable Unstable

How is the educational profile of child?
Below average Average  Above average Extra ordinary N. A.

Do you often catch the child daydreaming rather than taking interest in the present circumstances?
Yes No  May be, I can't guess

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