Dr. Megana Surapaneni

1. General Information

Parent Disclaimer: This tool is not a substitute for clinical diagnosis. Consult a healthcare professional for a comprehensive evaluation.

A. Child's Gender*

Boy

Girl

B. Child's Age*

1-2 years

2-3 years

3-4 years

4-5 years

5-6 years

6-8 years

8-12 years

12-16years

2. Fine Motor Skills

Skills involving small muscle movements, especially in the hands, like grasping or drawing.

A. Can your child pick up small objects using thumb and one finger?*

Never

Rarely

Sometimes

Always

B. Can your child stack two or more blocks?*

Never

Rarely

Sometimes

Always

C. Can your child turn the pages of a book one at a time?*

Never

Rarely

Sometimes

Always

A. Can your child draw a straight line?*

Never

Rarely

Sometimes

Always

B. Can your child use a spoon without spilling?

Never

Rarely

Sometimes

Always

C. Can your child open a jar or turn a doorknob?*

Never

Rarely

Sometimes

Always

A. Can your child cut paper with safety scissors?*

Never

Rarely

Sometimes

Always

B. Can your child open bottles, jars, or bag zips?*

Never

Rarely

Sometimes

Always

C. Can your child button their own shirt?*

Never

Rarely

Sometimes

Always

A. Can your child draw a square shape on paper?*

Never

Rarely

Sometimes

Always

B. Can your child lace up their own shoes?*

Never

Rarely

Sometimes

Always

C. Can your child use a Spoon and Fork properly?*

Never

Rarely

Sometimes

Always

A. Can your child draw a triangle shape on paper?*

Never

Rarely

Sometimes

Always

B. Can your child tie their own shoelaces?*

Never

Rarely

Sometimes

Always

C. Can your child write their own name?*

Never

Rarely

Sometimes

Always

A. Can your child write legible sentences?*

Never

Rarely

Sometimes

Always

B. Can your child use tools like scissors and rulers accurately?*

Never

Rarely

Sometimes

Always

C. Can your child tie complex knots?*

Never

Rarely

Sometimes

Always

A. Can your child write legibly and consistently with a pen or pencil?*

Never

Rarely

Sometimes

Always

B. Can your child manipulate small objects with precision, such as tying shoelaces or using keys?*

Never

Rarely

Sometimes

Always

C. Can your child accurately cut along a line or shape using scissors?*

Never

Rarely

Sometimes

Always

A. Can your child write legibly and quickly?*

Never

Rarely

Sometimes

Always

B. Can your child handle tools for schoolwork, like using a compass or protractor, with precision?*

Never

Rarely

Sometimes

Always

C. Can your child write legibly for extended periods, such as taking notes during a class lecture, without hand fatigue?*

Never

Rarely

Sometimes

Always

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Fine Motor Skills Sum

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Fine Motor Skills Recommendation

Occupational Therapy is strongly recommended to improve hand-eye coordination and object manipulation.

Monitor progress; consider periodical assessments to check if intervention becomes necessary.

Appears to be typically developing in fine motor skills; no immediate intervention needed.

3. Gross Motor Skills

Abilities using large muscles for movements like walking, running, and balancing.

A. Can your child walk without support?*

Never

Rarely

Sometimes

Always

B. Can your child kick a ball forward?*

Never

Rarely

Sometimes

Always

C. Can your child climb onto furniture unassisted?*

Never

Rarely

Sometimes

Always

A. Can your child run without tripping?*

Never

Rarely

Sometimes

Always

B. Can your child jump with both feet off the ground?*

Never

Rarely

Sometimes

Always

C. Can your child kick a ball forward?*

Never

Rarely

Sometimes

Always

A. Can your child climb stairs alternating feet?*

Never

Rarely

Sometimes

Always

B. Can your child hop on one foot?*

Never

Rarely

Sometimes

Always

C. Can your child ride a tricycle?*

Never

Rarely

Sometimes

Always

A. Can your child hop on one foot more than once?*

Never

Rarely

Sometimes

Always

B. Can your child catch a ball thrown towards him/her from 5 feet away?*

Never

Rarely

Sometimes

Always

C. Can your child balance on one foot for at least 5 seconds?*

Never

Rarely

Sometimes

Always

A. Can your child skip/hop for 10 steps in one go?*

Never

Rarely

Sometimes

Always

B. Can your child swing on a swing set, pumping their legs themselves?*

Never

Rarely

Sometimes

Always

C. Can your child perform a somersault?*

Never

Rarely

Sometimes

Always

A. Can your child ride a bicycle without training wheels?*

Never

Rarely

Sometimes

Always

B. Can your child catch a small ball using only their hands?*

Never

Rarely

Sometimes

Always

C. Can your child perform basic dance steps?*

Never

Rarely

Sometimes

Always

A. Can your child successfully engage in activities that require hand-eye coordination, such as catching a ball from 10 feet away?*

Never

Rarely

Sometimes

Always

B. Can your child handle utensils like a fork and knife proficiently while eating?*

Never

Rarely

Sometimes

Always

C. Can your child perform tasks that require both hands working together in a coordinated way, such as tying a knot or opening a jar?*

Never

Rarely

Sometimes

Always

A. Can your child maintain balance on one foot for at least 20 seconds without support?*

Never

Rarely

Sometimes

Always

B. Can your child execute activities that require sequential movements, like hopping over a series of obstacles?*

Never

Rarely

Sometimes

Always

C. Can your child perform activities that require coordination of both upper and lower body, like carrying a tray with water glasses or tea cups while navigating through a crowded space?*

Never

Rarely

Sometimes

Always

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Gross Motor Skill Sum

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Gross Motor Skill Recommendation

Physiotherapy is strongly recommended to improve mobility and coordination.

Monitor progress and physical development.

Appears to be typically developing in gross motor skills; no immediate intervention needed.

4. Language & Communication Skills

How your child speaks, understands, interacts, and communicates with others.

A. Does your child respond to simple commands like "come here"?*

Never

Rarely

Sometimes

Always

B. Can your child say at least three words?*

Never

Sometimes

Rarely

Always

C. Does your child point to objects or pictures when they are named?*

Never

Rarely

Sometimes

Always

A. Can your child form two-word sentences (e.g., "want milk")?*

Never

Rarely

Sometimes

Always

B. Does your child know their own name and age?*

Never

Rarely

Sometimes

Always

C. Can your child identify basic colours?*

Never

Rarely

Sometimes

Always

A. Can your child speak in full sentences?*

Never

Rarely

Sometimes

Always

B. Can your child name at least ten different objects?*

Never

Rarely

Sometimes

Always

C. Can your child understand and follow a three-step command? For example, "Pick up your toy, put it in the box, and then close the lid."*

Never

Rarely

Sometimes

Always

A. Can your child tell a simple story consisting of 10 lines?*

Never

Rarely

Sometimes

Always

B. Can your child form complete sentences in any language to ask for something specific, like requesting a particular snack or toy?*

Never

Rarely

Sometimes

Always

C. Can your child understand spatial words like "under" or "above," regardless of language?*

Never

Rarely

Sometimes

Always

A. Can your child speak clearly enough to be understood by people outside the family?Can your child speak clearly enough to be understood by people outside the family?*

Never

Rarely

Sometimes

Always

B. Can your child understand and answer who, what, where, why questions?*

Never

Rarely

Sometimes

Always

C. Can your child understand the concept of opposites (e.g., hot/cold, fast/slow)?*

Never

Rarely

Sometimes

Always

A. Can your child engage in detailed conversations, including back-and-forth dialogue?*

Never

Rarely

Sometimes

Always

B. Can your child read a simple paragraph, understand its meaning and explain to you in his/her own words?*

Never

Rarely

Sometimes

Always

C. Can your child understand simple figurative expressions, like saying something is "as fast as a car" to describe speed, in any language?*

Never

Rarely

Sometimes

Always

A. Can your child write a short essay or story that includes an introduction, body, and conclusion?*

Never

Rarely

Sometimes

Always

B. Can your child understand and correctly use figurative language, like explaining what the phrase "time flies" means?*

Never

Rarely

Sometimes

Always

C. "Can your child follow complex multi-step directions, such as 'Go to your room, pick up the blue book from your desk, and bring it to me in the living room'?"*

Never

Rarely

Sometimes

Always

A. Can your child articulate abstract concepts or emotions, such as explaining what "justice" or "freedom" means to them?*

Never

Rarely

Sometimes

Always

B. Can your child understand and interpret complex texts, like comprehending the main ideas of a news article or a book?*

Never

Rarely

Sometimes

Always

C. Can your child follow and engage in group discussions by both listening to others and contributing meaningful ideas?*

Never

Rarely

Sometimes

Always

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Language & Communication Sum

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Language & Communication Recommendation

Speech Therapy is strongly recommended to facilitate better communication skills.

Monitor progress; consult a speech therapist for possible early interventions.

Appears to be typically developing in language and communication; no immediate intervention needed.

5. Cognitive Skills

Abilities related to thinking, problem-solving, memory, and understanding concepts.

A. Can your child point to one body part when asked?*

Never

Rarely

Sometimes

Always

B. Does your child show interest in simple games like "peek-a-boo"?*

Never

Rarely

Sometimes

Always

C. Can your child fit a square block into a square hole?*

Never

Rarely

Sometimes

Always

A. Can your child sort objects by shape or colour?*

Never

Rarely

Sometimes

Always

B. Can your child complete a simple puzzle?*

Never

Rarely

Sometimes

Always

C. Does your child understand the concept of "two"?*

Never

Rarely

Sometimes

Always

A. Can your child recognize and name basic shapes?*

Never

Rarely

Sometimes

Always

B. Can your child count to ten?*

Never

Rarely

Sometimes

Always

C. Can your child match shapes or colours without assistance?*

Never

Rarely

Sometimes

Always

A. Can your child recognize and name all basic colours?*

Never

Rarely

Sometimes

Always

B. Can your child correctly identify and take out 3 objects from a set of 10?*

Never

Rarely

Sometimes

Always

C. Can your child understand the concept of time (e.g., morning, afternoon, night)?*

Never

Rarely

Sometimes

Always

A. Can your child recognize basic arithmetic symbols (plus, minus)?*

Never

Rarely

Sometimes

Always

B. Can your child identify the letters of the alphabet?*

Never

Rarely

Sometimes

Always

C. Can your child understand the concept of yesterday, today, and tomorrow?*

Never

Rarely

Sometimes

Always

A. Can your child perform basic arithmetic (addition and subtraction)?*

Never

Rarely

Sometimes

Always

B. Can your child group objects based on more than one attribute (e.g., colour and shape)?*

Never

Rarely

Sometimes

Always

C. Can your child tell the time on a watch?*

Never

Rarely

Sometimes

Always

A. Can your child perform multiplication and division?*

Never

Rarely

Sometimes

Always

B. Can your child understand the concept of percentages?*

Never

Rarely

Sometimes

Always

C. Can your child interpret simple graphs or charts?*

Never

Rarely

Sometimes

Always

A. Can your child organise and manage their time effectively to complete homework or projects by deadlines?*

Never

Rarely

Sometimes

Always

B. Can your child identify logical flaws in statements, such as spotting the error in "If it's raining, the ground is wet. The ground is wet, so it's raining"?*

Never

Rarely

Sometimes

Always

C. Can your child discuss ethical or moral dilemmas, such as what they would do if they found money on the street?*

Never

Rarely

Sometimes

Always

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Cognitive Skills Sum

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Cognitive Skills Recommendation

Cognitive Behaviour Therapy is strongly recommended for enhancing cognitive development.

Monitor cognitive skills; further assessments may be beneficial.

Appears to be typically developing cognitively; no immediate intervention needed.

6. Social & Emotional Skills

Understanding emotions, interactions, forming relationships, and connecting with others.

A. Does your child show attachment to familiar adults?*

Never

Rarely

Sometimes

Always

B. Does your child exhibit fear of strangers?*

Never

Rarely

Somtimes

Always

C. Does your child comfort themselves by thumb-sucking, holding a security object, etc.?*

Never

Rarely

Sometimes

Always

A. Does your child play alongside other children (parallel play)?*

Never

Rarely

Sometimes

Always

B. Does your child express affection openly?*

Never

Rarely

Sometimes

Always

C. Can your child understand simple "please" and "thank you" etiquette?*

Never

Rarely

Sometimes

Always

A. Does your child play cooperatively with other children for at least 15-20 minutes?*

Never

Rarely

Sometimes

Always

B. "Does your child try to comfort a crying peer or sibling by offering a toy or a hug?"*

Never

Rarely

Sometimes

Always

C. Does your child understand the concept of "mine" and "yours"?*

Never

Rarely

Sometimes

Always

A. Does your child cooperate with other children and can engage in group games?*

Never

Rarely

Sometimes

Always

B. Does your child follow household rules like not touching sharp objects or staying away from the stove?*

Never

Rarely

Sometimes

Always

C. Can your child recognize and verbally express basic emotions like happiness, sadness, or anger?*

Never

Rarely

Sometimes

Always

A. Does your child understand the concept of taking turns in games?*

Never

Rarely

Sometimes

Always

B. Can your child ask 'who, what, where, why' questions during storytime or conversations?*

Never

Rarely

Sometimes

Always

C. Can your child understand the concept of opposites, such as identifying that 'hot' is the opposite of 'cold' or 'fast' is the opposite of 'slow'?*

Never

Rarely

Sometimes

Always

A. Does your child exhibit sportsmanship in games, including losing gracefully?*

Never

Rarely

Sometimes

Always

B. Can your child distinguish between real events and pretend or imaginary scenarios, like understanding that a fairy tale is not a real story?*

Never

Rarely

Sometimes

Always

C. Does your child have at least one close friend?*

Never

Rarely

Sometimes

Always

A, Does your child understand the implications of gossip and rumours?*

Never

Rarely

Sometimes

Always

B. Can your child recognize and manage complex emotions like jealousy or embarrassment?*

Never

Rarely

Sometimes

Always

C. Can your child recognize and respond appropriately when someone is sad or upset, such as offering a comforting word or gesture?*

Never

Rarely

Sometimes

Always

A. Can your child understand the consequences of actions on their future, such as how skipping school could affect their grades?*

Never

Rarely

Sometimes

Always

B. Can your child navigate complex social situations, like resolving a disagreement among friends without escalating the conflict?*

Never

Rarely

Sometimes

Always

C. Does your child have a nuanced understanding of friendship and relationships, such as recognizing the importance of trust and communication?*

Never

Rarely

Sometimes

Always

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Social & Emotional Sum

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Social & Emotional Recommendation

Behavior Modification Therapy is strongly recommended to improve social and emotional skills.

Monitor social interactions and emotional responses.

Appears to be typically developing in social and emotional domains; no immediate intervention needed.

7. Adaptive Functioning

Daily self-help skills, including dressing, eating, and personal hygiene.

A. Can your child drink from a cup without spilling?*

Never

Rarely

Sometimes

Always

B. Can your child eat finger foods without assistance?*

Never

Rarely

Sometimes

Always

C. Can your child help in dressing themselves, like putting on a hat?*

Never

Rarely

Sometimes

Always

A. Can your child wash and dry their hands?*

Never

Rarely

Sometimes

Always

B. Can your child undress themselves?*

Never

Rarely

Sometimes

Always

C. Can your child drink from a cup without a lid?*

Never

Rarely

Sometimes

Always

A. Can your child put on his or her own clothes?*

Never

Rarely

Sometimes

Always

B. Can your child brush their teeth with assistance?*

Never

Rarely

Sometimes

Always

C. Can your child wash their hands unassisted?*

Never

Rarely

Sometimes

Always

A. Can your child pour liquid without spilling?*

Never

Rarely

Sometimes

Always

B. Can your child brush their teeth without assistance?*

Never

Rarely

Sometimes

Always

C. Can your child use the toilet unassisted?*

Never

Rarely

Sometimes

Always

A. Can your child pack their own school bag?*

Never

Rarely

Sometimes

Always

B. Can your child make a simple sandwich?*

Never

Rarely

Sometimes

Always

C. Does your child understand basic road safety rules, like waiting for a signal or holding an adult's hand near traffic?*

Never

Rarely

Sometimes

Always

A. Can your child prepare a simple meal (e.g., cereal, sandwich)?*

Never

Rarely

Sometimes

Always

B. Can your child take a shower without assistance?*

Never

Rarely

Sometimes

Always

C. Can your child make a simple purchase at a store?*

Never

Rarely

Sometimes

Always

A. Can your child use basic household appliances (e.g., microwave, washing machine)?*

Never

Rarely

Sometimes

Always

B. Can your child independently plan and execute a simple household chore, such as setting the table for dinner, without needing step-by-step guidance?*

Never

Rarely

Sometimes

Always

C. Can your child manage simple budgeting tasks (e.g., saving and spending pocket money)?*

Never

Rarely

Sometimes

Always

A. Can your child manage their own schedule and commitments?*

Never

Rarely

Sometimes

Always

B. Can your child prepare a full meal?*

Never

Rarely

Sometimes

Always

C. Can your child perform basic first aid?*

Never

Rarely

Sometimes

Always

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Adaptive Functioning Sum

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Adaptive Functioning Recommendation

Occupational Therapy is strongly recommended to enhance daily living skills.

Monitor progress in adapting to everyday tasks.

Appears to be typically developing in adaptive functioning; no immediate intervention needed.

8. Behavioural Issues

Patterns of actions or reactions that might be of concern, like aggression or withdrawal.

A. Does your child frequently have temper tantrums during activities like mealtime or bedtime that last for more than 10 minutes and are difficult to manage?*

Never

Rarely

Sometimes

Always

B. Does your child frequently bite or hit others?*

Never

Rarely

Sometimes

Always

C. Can your child sit still for short periods, such as while reading a story?*

Never

Rarely

Sometimes

Always

A. Does your child frequently defy or challenge adult requests, such as refusing to put away toys when asked?*

Never

Rarely

Sometimes

Always

B. Does your child show extreme separation anxiety from primary caregivers, such as crying excessively when left with relatives or ayahs?*

Never

Rarely

Sometimes

Always

C. Does your child often seem unusually withdrawn, avoiding social interactions during family gatherings*

Never

Rarely

Sometimes

Always

A. Does your child frequently interrupt conversations?*

Never

Rarely

Sometimes

Always

B. Does your child struggle with sharing toys?*

Never

Rarely

Sometimes

Always

C. Does your child exhibit mood swings, such as going from happy to irritable, when transitioning between activities or places?*

Never

Rarely

Sometimes

Always

A. Does your child continue to defy rules like running indoors or using toys improperly even after multiple corrections?*

Never

Rarely

Sometimes

Always

B. Does your child struggle to calm down after playing tag or receiving an exciting gift?*

Never

Rarely

Sometimes

Always

C. Does your child struggle with making eye contact during conversations?*

Never

Rarely

Sometimes

Always

A. Does your child frequently argue with adults, especially during mealtime or bedtime routines?*

Never

Rarely

Sometimes

Always

B. Does your child exhibit signs of excessive shyness or withdrawal during social events or group activities?*

Never

Rarely

Sometimes

Always

C. Does your child frequently interrupt others, especially while they are speaking or engaged in an activity?*

Never

Rarely

Sometimes

Always

A. Does your child have emotional outbursts, such as crying or yelling, that seem disproportionate to situations like losing a game or receiving a minor correction?*

Never

Rarely

Sometimes

Always

B. Does your child show signs of anxiety, like excessive worrying or phobias?*

Never

Rarely

Sometimes

Always

C. Does your child exhibit repetitive behaviours (e.g., hand-flapping, rocking)?*

Never

Rarely

Sometimes

Always

A. Does your child exhibit mood swings that seem extreme, such as going from joyful to angry in a short span of time without a clear reason?*

Never

Rarely

Sometimes

Always

B. Does your child engage in risky behaviour, like climbing high places or running across the street without looking, without considering the potential consequences?*

Never

Rarely

Sometimes

Always

C. Does your child frequently challenge authority figures, such as teachers or parents, by openly defying rules or instructions?*

Never

Rarely

Sometimes

Always

A. Does your child engage in behaviours that are risky, such as attempting stunts or dares that could result in injury?*

Never

Rarely

Sometimes

Always

B. Does your child exhibit signs of emotional withdrawal that seem excessive, such as avoiding social interactions for extended periods, even with close family and friends?*

Never

Rarely

Sometimes

Always

C. Does your child frequently clash with authority figures, such as arguing with teachers or openly defying household rules?*

Never

Rarely

Sometimes

Always

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Behavioural Issues Sum

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Behavioural Issues Recommendation

Behavior Modification Therapy or Cognitive Behaviour Therapy is strongly recommended for behavioural issues.

Monitor behaviour; consult a psychologist if issues persist.

Appears to be typically developing in behaviour; no immediate intervention needed.

9. Sensory Processing

A. Does your child react negatively to new textures like grass or sand?*

Never

Rarely

Sometimes

Always

B. Is your child sensitive to lights or sounds that don't seem to bother other kids?*

Never

Rarely

Sometimes

Always

C. Does your child avoid or seem bothered by messy activities like finger painting?*

Never

Rarely

Sometimes

Always

A. Is your child disturbed by everyday sounds such as a vacuum cleaner or a dog barking?*

Never

Rarely

Sometimes

Always

B. Does your child have difficulty transitioning from one activity to another, for example, from playtime to mealtime?*

Never

Rarely

Sometimes

Always

C. Does your child refuse to touch certain textures like sand, playdough, or wet food?*

Never

Rarely

Sometimes

Always

A. Does your child get overly upset by loud noises or bright lights?*

Never

Rarely

Sometimes

Always

B. Is your child extremely picky about food textures, such as refusing to eat mushy foods like 'khichdi' or crunchy foods like 'papad'?*

Never

Rarely

Sometimes

Always

C. Does your child become clingy or irritable in new settings like a different park or relatives home?*

Never

Rarely

Sometimes

Always

A. Is your child extremely sensitive to smells?*

Never

Rarely

Sometimes

Always

B. Does your child still have difficulty adapting to new textures of clothing or food?*

Never

Rarely

Sometimes

Always

C. Does your child exhibit a strong aversion to everyday sounds like a vacuum cleaner or clapping?*

Never

Rarely

Sometimes

Always

A. Is your child overly sensitive to environmental stimuli like sirens or fireworks?*

Never

Rarely

Sometimes

Always

B. Is your child extremely picky about food textures, such as refusing to eat mushy foods like 'khichdi' or crunchy foods like 'papad'?*

Never

Rarely

Sometimes

Always

C. Does your child have difficulty adapting to changes in lighting or volume?*

Never

Rarely

Sometimes

Always

A. Does your child show noticeable discomfort or irritation with certain textures, such as refusing to wear certain fabrics or eat specific foods?*

Never

Rarely

Sometimes

Always

B. Does your child exhibit a strong preference or aversion to certain smells, such as reacting strongly to the scent of specific foods or cleaning products?*

Never

Rarely

Sometimes

Always

C. Does your child have difficulty focusing on tasks like homework or reading when there's background noise, such as TV or people talking?*

Never

Rarely

Sometimes

Always

A. Does your child exhibit sensitivity to specific textures in food, such as avoiding foods that are crunchy or slimy?*

Never

Rarely

Sometimes

Always

B. Is your child overly sensitive to loud noises, such as covering their ears during everyday events like traffic or household appliances being used?*

Never

Rarely

Sometimes

Always

C. Does your child have difficulty adapting to changes in temperature, like becoming overly distressed during hot or cold weather?*

Never

Rarely

Sometimes

Always

A. Does your child have difficulties with sensory overload in crowded or noisy environments?*

Never

Rarely

Sometimes

Always

B. Is your child overly sensitive or intolerant to specific food textures or tastes?*

Never

Rarely

Sometimes

Always

C. Does your child have difficulties adjusting to new sensory experiences (e.g., new clothing materials)?*

Never

Rarely

Sometimes

Always

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Sensory Processing Sum

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Sensory Processing Recommendation

Auditory Integration or Sensory Integration Therapy is strongly recommended for sensory issues.

Monitor sensory reactions to various stimuli.

Appears to be typically developing in sensory processing; no immediate intervention needed.

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ASD Sum

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ASD

ASD Risk Level

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ADHD Sum

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ADHD

ADHD Risk Level

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Developmental Delay Sum

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Developmental Delay

Developmental Delay Risk Level

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Emotional Disorders Sum

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Emotional Disorders

Emotional Disorders Risk Level

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Intellectual Disorders Sum

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Intellectual Disorder

Intellectual Disorder Risk Level

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Learning Delays Sum

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Learning Delay

Learning Delay Risk Level

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Condition Recommendation

10. Parent/Guardian & Child Details

Enter details for both the parent/guardian and child to ensure accurate assessment feedback.

Child's Name*

First Name Last Name

Email*

Mobile*

Location*

City Country

Consent*

I have read and understood the information provided above and consent to the assessment.

Growth & Strategic Partnerships Lead