英語の問診票（10か月児用）

英語版問診票（10か月児用）
1.Does your child twist his/her body to take objects on his/her side or behind.			yes	no
2. Does your child make eye contact with you?			yes	no
3. Do you have any concern with your child's vision and eye movement?			yes	no
4.Does your child speak some words such as "mamama" or "papapa"?			yes	no
5. Does your child turn around when you whisper to him/her?			yes	no
6. Does your child respond to phone calls and chimes?			yes	no
7. Does your child have stranger anxiety?			yes	no
8. Does your child try to follow you?			yes	no
9. Does your child respond back to simple gestures like waving goodbye?			yes	no
10.Does your child like to play by himself/herself?			yes	no
11. Did your child receive the medical examination of congenital hip dislocation?			yes	no
12. Do you have concerns about your child's behavior or habits?			yes	no
If yes, please write down detail

13. how many times do you(mother) eat food?			times
1）. breakfast 2）. lunch 3）. dinner 4）. and so on
14.Is the interval between feedings nearly constant?			yes	no
15. What kind of milk does your child drink?		1. breastfeeding	2. formula	3.mixed
how many times in a day?			times
16. Has your child started eating solid food?When?		around months
17. How often do you give baby food to your child?			yes	no
18. Does your child chew well?			yes	no
19.Has your child been diagnosed with a food allergy from a doctor?			yes	no
If yes, (1)now under treatment? or (2)under obserbvation?			(1)	(2)
20.What kind of food do you feed your child? Write down in detail.

21. If there is anything your child eats or drinks other than child food, write down in detail.

22. Do you keep your baby's mouth clean?(ex.brush his/her teeth)			yes	no
23. Have you ever used cup to give child something to drink?			yes	no
24.Are you worried about the way your child's teeth are coming in, their shape/color or about the child's gums?			yes	no
※if yes, please write.
25.Describe your current state.
a)Do you enjoy spending time with your child？			yes	no
b)Do you fell anxious about childcare?			yes	no
c)Are you tired of childcare?			yes	no
d)Do you often slap and scold your child?			yes	no
26.Is the child’s father involved in childcare?			yes	no
27. Is there anyone who helps you with childcare(excluding father)?			yes	no
→who is it
28. Can you relax with your child?			yes	no
29. Are you having trouble with raising your child?			yes	no
30.Is there anyone to talk about childraising when you are having trouble?			yes	no
31.Is there anyone you feel comfortable asking for advice about raising a child?	Who?
32.Do you read picture books to your child?			yes	no
33. How many hours do you show your child any video such as TVs, DVDs or Smartphones?			mins
34.Does anyone in your family smoke?			yes	no
If yes,who and how many?( ___________/ ___________)

英語の問診票（10か月児用）

カテゴリー

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英語の問診票（10か月児用）

カテゴリー

手続きナビゲーション

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