英語の問診票（4か月児用）

問診票（4か月児用）
1.Did you receive adequate guidance and care from a midwife or a puclic health nurse?			yes		no
2.Did the child's mother smoke during pregnancy?			no		yes
3.Did the child's father smoke during pregnancy?			no		yes
4.Does the child's mother smoke,now?			no		yes
5.Does the child's father smoke?			no		yes
6.Did the child's mother drink alcohol during pregnancy?			no		yes
7.What did you feed your child when he/she was one month old?	1. breastmilk	2. formula		3.mixed
8.What do you feed your child now?How much and how often?
☆breast milk ：＿＿＿＿times☆formula ：＿＿＿＿ml×＿＿＿＿times
9.Do you want to raise your child in this area in the future?			yes		no
10.Is the child’s father involved in childcare?			yes		no
11.Is there anyone who helps you with childcare(except the father)?			yes		no
12.Can you relax with your child?			yes		no
13.Are you having trouble with raising your child?			no		yes
14.Is there anyone to talk about childraising when you are having trouble?			yes		no
15.Is there anyone you feel comfortable asking for advice about raising a child?			yes		no
16.Are you aware that children age sixmonth to around one year old follow their parents,around?			yes		no
17.Did any of the following apply to you in the past few months? Please circle all that apply.
a).Too much discipline b).Spank your infant’s body, etc. emotionally c).Going out and leaving only your infant at home d).Fail to give your infant any food for a long time e).Emotionally yell in anger f).Cover your infant’s mouth g).Strongly shake your infant’s body, etc. h).None of the above apply



18.Do you know that brain damage can be caused by violently shaking a child's head when the child won't stop crying (infant shaking syndrome)?			yes		no
19.Do you know the Pediatric Emergency Telephone Consultation (#8000)?			yes		no
20.Does your child have a family doctor?			yes		no
21.Were you working during your pregnancy?			yes		no
22.If yes, do you think your workplace gave you consideration for continuing to work during your pregnancy?			yes		no
23.Did you know about the maternity mark during your pregnancy?			yes		no
24.Have you ever used a maternity mark?			yes		no
25.Does your child laugh aloud when you touch or hold him/her?			yes		no
26.When you talk to your child, does he/she make "aa, aa", "woo, woo" or other sounds?			yes		no
27.Does your child try to look in the direction of your voice when you call him/her from a place out of the child's sight?			yes		no
28.Is there anything unusual in your child's eye movement or expression?			no		yes
29.Does your child grab what he/she touch in his/her hand?			yes		no
30.Does your child lick his/her hand or fingers?			yes		no
31.When you hold your child, do you feel anything strange such as that his/her body is too soft, his/her hands and feet are stiff, or that he/she tends to lean back, etc.?			no		yes
32.Has your child had a congenital hip dislocation screening?			yes		no
33.Describe your current state.
a)Do you enjoy spending time with your child？			yes		no
b)Do you feel anxious about childcare?			yes		no
c)Are you tired of childcare?			yes		no
d)Do you often slap and scold your child?			yes		no
34.Has your child been diagnosed with a food allergy from a doctor?			no		yes
If yes, (1)now under treatment? or (2)under obserbvation?			(1)		(2)

英語の問診票（4か月児用）

カテゴリー

手続きナビゲーション

英語の問診票（4か月児用）

カテゴリー

手続きナビゲーション

最近チェックしたページ

このページを見た人はこんなページも見ています