| 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?( ___________/ ___________) | ||||||||||