さくら市英語の問診票（1歳6か月用）

英語版問診票（1歳6か月児用）
1.Does the child's mother smoke,now?	no	yes
2.Does the child's father smoke,now?	no	yes
3.Do you brush your child’s teeth as finishing every day?
a).Yes (the guardian always brushes the child’s teeth after the child brushes his/her teeth by himself/herself).
b).Yes (the guardian only brushes the child’s teeth).
c).No (the child only brushes the his/her teeth).
d).No (both the guardian and the child do not brush his/her teeth).
4.Has your child already got DPT-IPV vaccine for diphtheria, whooping cough, tetanus and polio (1st period: 3 times firstly)?	yes	no
5.Has your child already got rubella/measles vaccine?	yes	no
6.Do you want to raise your child in this area in the future?	yes	no
7.Is the child’s father involved in childcare?	yes	no
8.Is there anyone who helps you with childcare(except the father)?	yes	no
9.Is the door in a bathroom taken any idea not to be opened solely by your child?	yes	no
10.Can you relax with your child?	yes	no
11.Are you having trouble with raising your child?	no	yes
12.Is there anyone to talk about childraising when you are having trouble?	yes	no
13.Do you know that most infants aged approximately one and a half years – two years try to point their own finger at something interested in?	yes	no
14.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
15.Does your child walk well on his/her own?	yes	no
16.Does your child imitate the behavior of others (wave hands or say bye-bye, etc.)?	yes	no
17.Does your child seem to enjoy playing with you?	yes	no
18.Is your child interested in another child (ex. getting closer to another child)?	yes	no
19.Does your child play within your reach?	yes	no
20.Does your child ask you help when he/she is scared or in trouble?	yes	no
21.If you ask your child about something to know (“What is a dog (Wan-wan)?” etc.) while reading any picture book, does your infant point out the things?	yes	no
22.Do you have any worries about your child’s eye movement or hearing, etc.?	no	yes
23.Does your child try to use a spoon, etc. to eat something?	yes	no
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

英語版問診票（1歳6か月児用）

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

yes

2.Does the child's father smoke,now?

yes

3.Do you brush your child’s teeth as finishing every day?

a).Yes (the guardian always brushes the child’s teeth after the child brushes his/her teeth by himself/herself).

b).Yes (the guardian only brushes the child’s teeth).

c).No (the child only brushes the his/her teeth).

d).No (both the guardian and the child do not brush his/her teeth).

4.Has your child already got DPT-IPV vaccine for diphtheria, whooping cough, tetanus and polio (1st period: 3 times firstly)?

yes

5.Has your child already got rubella/measles vaccine?

yes

6.Do you want to raise your child in this area in the future?

yes

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

yes

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

yes

9.Is the door in a bathroom taken any idea not to be opened solely by your child?

yes

10.Can you relax with your child?

yes

11.Are you having trouble with raising your child?

yes

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

yes

13.Do you know that most infants aged approximately one and a half years – two years try to point their own finger at something interested in?

yes

14.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

15.Does your child walk well on his/her own?

yes

16.Does your child imitate the behavior of others (wave hands or say bye-bye, etc.)?

yes

17.Does your child seem to enjoy playing with you?

yes

18.Is your child interested in another child (ex. getting closer to another child)?

yes

19.Does your child play within your reach?

yes

20.Does your child ask you help when he/she is scared or in trouble?

yes

21.If you ask your child about something to know (“What is a dog (Wan-wan)?” etc.) while reading any picture book, does your infant point out the things?

yes

22.Do you have any worries about your child’s eye movement or hearing, etc.?

yes

23.Does your child try to use a spoon, etc. to eat something?

yes

24.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)

25.Does your child have any problems with appetite or picky eating?

yes

26.Describe your current state.

a)Do you enjoy spending time with your child？

yes

b)Do you fell anxioas about childcare?

yes

c)Are you tired of childcare?

yes

d)Do you often slap and scold your child?

yes

27.Do you read picture books to your child?

yes

28.How many hours do you show your child any video such as TVs, DVDs or Smartphones?

minutes

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