英語の問診票（3歳6か月児用）

英語版問診票（3歳6か月児用）
1.Does the child's mother smoke?	no	yes
2.Does the child's father smoke?	no	yes
3.Do you want to raise your child in this area in the future?	yes	no
4.Is the child’s father involved in childcare?	yes	no
5.Is there anyone who helps you with childcare(except the father)?	yes	no
6.Can you relax with your child?	yes	no
7.Are you having trouble with raising your child?	no	yes
8.Is there anyone to talk about childraising when you are having trouble?	yes	no
9.Is there anyone you feel comfortable asking for advice about raising a child?	yes	no
11.Did any of the following apply to you in the past few months? Please circle all that apply.




12.Does your child have a family doctor?	yes	no
13.Does your child have a family dentist?	yes	no
14.Can your child easily climb the stairs without using his/her hands?	yes	no
15.Can your child jump on one leg?	yes	no
16.Can your child have a conversation with children of the same age?	yes	no
17.Do you have any worries about your child’s speaking?	no	yes
18.Does your child play make-believe games such as playing trains, playing house, etc.?	yes	no
19.Can your child take off his/her jacket by him/herself?	yes	no
20.Can your child eat well with chopsticks or a spoon without spilling much?	yes	no
21.Do you have trouble with your child being terribly restless and unable to concentrate?	no	yes
22.Do you have trouble with your child being extremely fearful or anxious?	no	yes
23.Do you have trouble with your child’s stranger anxiety?	no	yes
24.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)
25.Does your child have any problems with appetite or picky eating?	no	yes
26.Describe your current state.
a)Do you enjoy spending time with your child？	yes	no
b)Do you fell anxioas about childcare?	yes	no
c)Are you tired of childcare?	yes	no
d)Do you often slap and scold your child?	yes	no
27.Do you read picture books to your child?	yes	no
28.How many hours do you show your child any video such as TVs, DVDs or Smartphones?	minutes
29.Is there anyone in your family who is deaf?	no	yes
→If yes,who?
30.Has your child ever contracted otitis media?	no	yes
31.Does your child often have nasal congestion, nasal drip,breathe through their mouth, or dry throat?	no	yes
32.Have you ever wondered if your child is hard of hearing due to not responding when called, asking you to repeat yourself, or watching loud television?	no	yes
33.Has anyone in close contact with your child (daycare staff, etc) ever said that your child is hard of hearing?	no	yes
34.Do you ever need to supplement your speech with gestures in order to be understood?	no	yes
35.Did you get any illnesses such as high fevers, rubella or mumps during the child's pregnancy?	no	yes
36.Have you ever had any concerns about your child’s speech being slow, having odd pronunciation, etc?	no	yes
37.Does your child's eyes ever shift inward or outward or up?	no	yes
38.Does your child glarely close one eye when looking into the distance?	no	yes
39.Does your child constantly squint? (Except when looking at the sun or other bright objects )	no	yes
40.Does your child move closer to or squint when he/she looks at an object?	no	yes
41.Does your child often tilt his/her face or look sideways?	no	yes

英語の問診票（3歳6か月児用）

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英語の問診票（3歳6か月児用）

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