さくら市トップ
> 英語の問診票(3歳6か月児用)
英語の問診票(3歳6か月児用)
掲載日 令和5年8月8日
更新日 令和5年8月10日
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 |
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健康福祉部 こども家庭センター 子育て世代支援係
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