さくら市英語の問診票（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)

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

2.Did the child's mother smoke during pregnancy?

yes

3.Did the child's father smoke during pregnancy?

yes

4.Does the child's mother smoke,now?

yes

5.Does the child's father smoke?

yes

6.Did the child's mother drink alcohol during pregnancy?

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

10.Is the child’s father involved in childcare?

yes

11.Is there anyone who helps you with childcare(except the father)?

yes

12.Can you relax with your child?

yes

13.Are you having trouble with raising your child?

yes

14.Is there anyone to talk about childraising when you are having trouble?

yes

15.Is there anyone you feel comfortable asking for advice about raising a child?

yes

16.Are you aware that children age sixmonth to around one year old follow their parents,around?

yes

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

19.Do you know the Pediatric Emergency Telephone Consultation (#8000)?

yes

20.Does your child have a family doctor?

yes

21.Were you working during your pregnancy?

yes

22.If yes, do you think your workplace gave you consideration
for continuing to work during your pregnancy?

yes

23.Did you know about the maternity mark during your pregnancy?

yes

24.Have you ever used a maternity mark?

yes

25.Does your child laugh aloud when you touch or hold him/her?

yes

26.When you talk to your child, does he/she make "aa, aa", "woo, woo" or other sounds?

yes

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

28.Is there anything unusual in your child's eye movement or expression?

yes

29.Does your child grab what he/she touch in his/her hand?

yes

30.Does your child lick his/her hand or fingers?

yes

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.?

yes

32.Has your child had a congenital hip dislocation screening?

yes

33.Describe your current state.

a)Do you enjoy spending time with your child？

yes

b)Do you feel anxious about childcare?

yes

c)Are you tired of childcare?

yes

d)Do you often slap and scold your child?

yes

34.Has your child been diagnosed with a food allergy from a doctor?

yes

If yes, (1)now under treatment? or (2)under obserbvation?

(1)

(2)

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