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CARTA CIRCULAR # M1911098 A TODOSOSRUPOS G...
Transcript of CARTA CIRCULAR # M1911098 A TODOSOSRUPOS G...
PSGPROV_2019_131_S
CARTA CIRCULAR # M1911098
25 de octubre de 2019
A TODOS LOS GRUPOS MÉDICOS PRIMARIOS Y PROVEEDORES PARTICIPANTES DEL PLAN DE SALUD DEL GOBIERNO, VITAL (PLAN VITAL)
Re: Detección Temprana y Periódica, Diagnóstico, y Tratamiento (EPSDT, por sus siglas en inglés)
¿Qué es EPSDT?
• EPSDT son las siglas de Early and Periodic Screening, Diagnosis and Treatment (DetecciónTemprana y Periódica, Diagnóstico, y Tratamiento, en español).
• Es un programa de pruebas preventivas para la población de Medicaid, cubierto bajo losbeneficios del Plan Vital, que se realizan de forma periódica, según la edad del menor (0 hastalos 21 años), con el propósito de identificar temprano posibles problemas de salud.
¿Quién es elegible a EPSDT?
• Todos los niños elegibles al programa de Medicaid, “Children’s Health Insurance Program”(CHIP) y beneficiarios del Plan Vital, menores de 21 años de edad.
• Mujeres en estado de embarazo.
¿Qué servicios están considerados en EPSDT?
• Servicios de cernimiento, diagnóstico, tratamiento (incluyendo referidos) indispensable paracorregir o aminorar cualquier deficiencia y condiciones crónicas descubiertas.
• EPSDT ofrece cuatro tipos de exámenes: médico, visión, audición y dental.
• Los servicios de EPSDT están programados a intervalos de edad apropiados para que los niñosreciban los servicios necesarios para mantener su salud.
¿Cuáles son algunos de los servicios y evaluaciones incluidos?
• Historial comprensivo de salud y desarrollo;
• Examen físico sin ropa- Incluye gráficos de peso, altura y crecimiento;
• Educación para la salud el cual incluye la orientación anticipada;
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• Vacunación - De acuerdo al Itinerario de Vacunación de Niños y Adolescentes;
• Pruebas de laboratorio según la edad y el historial de salud - Incluye la prueba de toxicidad del plomo y VIH;
• Evaluación nutricional;
• Educación en Salud - Incluyendo temas como el desarrollo del paciente, estilos de vida saludables y prevención de accidentes, enfermedades y conductas de riesgo;
• Cernimientos de salud mental - Autismo, depresión y condiciones socioemocionales;
• Evaluación del desarrollo - Mediante instrumento de cernimiento validado. Ages and Stages (ASQ) última edición o Survey Wellbeing Young Children (SWYC);
• Servicios de visión y audición - Incluyen como parte de la cubierta, servicios de diagnóstico y tratamiento para defectos de la vista y de audición, de acuerdo con el esquema de periodicidad establecido;
• Servicios dentales - Debe ser parte del examen físico de rutina, pero no debe sustituir el referido apropiado para la visita al dentista de acuerdo con el esquema de periodicidad establecido.
¿Qué sucede luego de identificar un problema médico?
• Si los servicios de detección indican que existe la necesidad de una evaluación más completa de la salud del niño o de una condición específica, esa evaluación y diagnóstico deben ser coordinados y suministrados sin demora.
• EPSDT requiere que a través de la cubierta que ofrece el Plan Vital se coordinen, por medio de referidos, los tratamientos u otras medidas necesarias para corregir o mejorar enfermedades físicas o mentales que surjan como resultado de las pruebas de detección.
• Si un proveedor de salud determina que un servicio es médicamente necesario para corregir o aminorar un problema de salud, entonces EPSDT debe cubrir el servicio.
¿Qué restricciones tienen los servicios de EPSDT?
• Los servicios que se ofrezcan o soliciten deben ser medicamente necesarios;
• Algunos servicios de tratamiento pueden requerir una autorización previa;
• EPSDT no puede proporcionar servicios que se consideren peligrosos o experimentales. El proveedor, como parte del Grupo Médico Primario (GMP), es responsable de brindar los servicios antes mencionados y dar seguimiento en los intervalos de tiempo recomendados según las guías clínicas de pediatría Bright Futures.
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Para su beneficio, adjuntamos los siguientes documentos relacionados al Programa Early and Periodic Screening Diagnosis and Treatment (EPSDT) del Plan Vital:
• Guías de Servicios Pediátricos Preventivos del Departamento de Salud (publicadas previamente en Carta Circular # M1807203 del 14 de noviembre de 2018)
• Cernimiento del Desarrollo: Survey Wellbeing Young Children (SWYC) Para mayor información sobre el programa de EPSDT le incluimos el siguiente enlace a la página de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés): https://www.medicaid.gov/medicaid/benefits/epsdt/index.html Acompañamos las recomendaciones de Bright Futures y la Academia Americana de Pediatría para la atención preventiva de la salud pediátrica, también conocido como “Esquema de Periodicidad”. Enlace: https://www.aap.org/en-us/Documents/periodicity_schedule.pdf Del mismo modo, anejamos los siguientes enlaces de referencia para las pruebas de cernimiento recomendadas:
• MCHAT y MCHAT-R/F https://mchatscreen.com/ https://mchatscreen.com/wp-content/uploads/2015/05/M-CHAT-R_F_Spanish_Spain.pdf https://mchatscreen.com/wp-content/uploads/2015/05/MCHAT-R_Spain_20pictures.pdf https://mchatscreen.com/wp-content/uploads/2015/05/M-CHAT_Spanish_Spain.pdf https://mchatscreen.com/wp-content/uploads/2015/05/M-CHAT_Spanish_Spain_FollowUp.pdf
• SWYC https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-Young-Children/Age-Specific-Forms https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-Young-Children/Translations/Spanish-SWYC Para calcular puntuación de los hitos: https://www.floatinghospital.org/The-Survey-of-Wellbeing-of-Young-Children/Choose-a-Form-Score-the-SWYC
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• Ages and Stages (ASQ) https://agesandstages.com/
• Caries-Risk Assessment Questionnaire
https://www.aap.org/en-us/Documents/oralhealth_RiskAssessmentTool.pdf https://www.aap.org/en-us/Documents/oralhealth_RiskAssessmentToolSpanish.pdf
• CRAFFT o Carlos https://crafft.org/wp-content/uploads/2018/04/Spain-SpanishCRAFFT20Clinician-Interview20170208.pdf
• Cuestionario para Evaluar Riesgo de Tuberculosis en Poblaciones Pediátricas http://www.salud.gov.pr/Dept-de-Salud/Documents/Cuestionario%20para%20Evaluar%20Riesgo%20de%20Tuberculosis%20en%20Poblaciones%20Pedi%C3%A1tricas.pdf
• Cernimiento de depresión “Patient Health Questionnaire” (PHQ-9) https://aidsetc.org/sites/default/files/resources_files/PHQ-9_English.pdf https://aidsetc.org/sites/default/files/resources_files/PHQ-9_Spanish.pdf
• Bright Futures https://brightfutures.aap.org/Pages/default.aspx
Le exhortamos a todos los Grupos Médicos Primarios y Proveedores Participantes del Plan Vital a cumplir con los servicios preventivos requeridos para nuestros beneficiarios y con la codificación adecuada para dichos servicios. De tener alguna duda o pregunta, puede comunicarse con el Centro de Servicio al Proveedor al 1-844-263-6063. Nuestro Centro de Llamadas está disponible de lunes a domingo de 7:00 a.m. a 7:00 p.m. Cordialmente Josefina Díaz Hernández, BHE, MHR Senior Manager Preventive Management Department Anejos
Todavía No Algunas Veces Mucho
Junta las manos ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se ríe ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sostiene la cabeza cuando usted lo sienta ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Hace sonidos como “ga,” “ma,” o “ba” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Lo mira cuando usted dice su nombre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)
Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Hace sonidos que le permite saber a usted que él/ella esta feliz o molesto ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Parece feliz al verlo/a ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sigue con la mirada un juguete en movimiento ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Mueve la cabeza para buscar a la persona que está hablando ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Mantiene la cabeza firme mientras usted lo levanta ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 2 meses 1 mes, 0 días to 3 meses, 31 días
1 month, 0 days to 3 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Agarra dos objetos y los golpea uno contra el otro ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sostiene la cabeza cuando usted lo sienta ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Hace sonidos como “ga,” “ma,” o “ba” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Lo mira cuando usted dice su nombre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se da vueltas (se rueda sobre sí mismo) ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pasa un juguete de una mano a la otra ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cuando él/ella se molesta, lo busca a usted u otra persona conocida ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)
Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Junta las manos ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Mantiene la cabeza firme mientras usted lo levanta ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se ríe ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 4 meses 4 meses, 0 días to 5 meses, 31 días
4 months, 0 days to 5 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Se da vueltas (se rueda sobre sí mismo) ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Hace sonidos como “ga,” “ma,” o “ba” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Lo mira cuando usted dice su nombre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se sostiene para levantarse hasta quedar de pie ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pasa un juguete de una mano a la otra ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cuando él/ella se molesta, lo busca a usted u otra persona conocida ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Agarra dos objetos y los golpea uno contra el otro ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Alza los brazos para ser levantado ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Puede sentarse sin ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Agarra comida y la come ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 6 meses 6 meses, 0 días to 8 meses, 31 días
6 months, 0 days to 8 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Sigue instrucciones – por ejemplo “Ven acá” o “Dame la pelota” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se sostiene para levantarse hasta quedar de pie ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Juega a juegos como “¿Dónde está el bebe?” o “peek-a-boo” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙Lo llama a usted "mama" o "papa" o algo parecido ∙ ∙ ∙ ∙ ∙ ∙ ∙
Mira a su alrededor cuando usted dice cosas como: “¿Dónde está tu biberón?”
o “¿Dónde está tu juguete?
Imita sonidos que usted hace ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cruza una habitación caminando sin ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Puede sentarse sin ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Alza los brazos para ser levantado ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Agarra comida y la come ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 9 meses 9 meses, 0 días to 11 meses, 31 días
9 months, 0 days to 11 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Agarra comida y la come ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Se sostiene para levantarse hasta quedar de pie ∙ ∙ ∙ ∙ ∙ ∙
Juega a juegos como“¿Dónde está el bebe?” o “peek-a-boo”
Lo llama a usted "mama" o "papa" o algo parecido ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Imita sonidos que usted hace ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cruza una habitación caminando sin ayuda ∙ ∙ ∙ ∙ ∙ ∙
Sigue instrucciones – por ejemplo “Ven acá” o “Dame la pelota” ∙
Corre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sube escaleras caminando con ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Mira a su alrededor cuando usted dice cosas como: “¿Dónde está tu biberón?”
o “¿Dónde está tu juguete?
Pautas Madurativas: 12 meses 12 meses, 0 días to 14 meses, 31 días
12 months, 0 days to 14 months, 31 days
V1.07, 4/1/17
∙
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Alguna Veces Mucho
Imita sonidos que usted hace ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Mira a su alrededor cuando usted dice cosas como: “¿Dónde está tu biberón?”
o “¿Dónde está tu juguete?
Lo llama a usted "mama" o "papa" o algo parecido ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cruza una habitación caminando sin ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sigue instrucciones – por ejemplo “Ven acá” o “Dame la pelota” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙
Corre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sube escaleras caminando con ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Patea la pelota ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Nombra por lo menos 5 objetos familiares – por ejemplo pelota o leche ∙ ∙
Nombra por lo menos 5 partes del cuerpo – por ejemplo nariz, mano, o boca ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 15 meses 15 meses, 0 días to 17 meses, 31 días
15 months, 0 days to 17 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
∙ ∙ ∙ ∙ ∙ ∙ ∙
Todavía No Algunas Veces Mucho
∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙
Corre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sube escaleras caminando con ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Patea la pelota ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Nombra por lo menos 5 objetos familiares – por ejemplo pelota o leche ∙ ∙
Nombra por lo menos 5 partes del cuerpo – por ejemplo nariz, mano, o boca ∙
Sube escaleras en el parque de juegos ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Usa palabras como “yo” o “mío” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Salta en el suelo con los dos pies ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Junta 2 o más palabras – par ejemplo “más agua” o “quiero leche"
Usa palabras para pedir ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 18 meses 18 meses, 0 días to 22 meses, 31 días
18 months, 0 days to 22 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Usa palabras como “yo” o “mío” ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sube escaleras en el parque de juegos ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Nombra por lo menos 5 partes del cuerpo – por ejemplo nariz, mano, o boca ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Salta en el suelo con los dos pies ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Junta 2 o más palabras – por ejemplo “más agua” o “quiero leche"
Usa palabras para pedir ayuda ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Nombra por lo menos un color ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Intenta hacer que usted lo mire diciendo “Mírame” ∙ ∙ ∙
Dice su nombre cuando se lo preguntan ∙ ∙ ∙ ∙ ∙
Dibuja líneas ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 24 meses 23 meses, 0 días to 28 meses, 31 días
23 months, 0 days to 28 months, 31 days
V1.07, 4/1/17
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Contesta preguntas como “¿Qué haces cuando tienes frío?” o “¿…cuando
tienes sueño?
∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Hace preguntas que empiezan con “por qué” o “cómo” – por ejemplo “¿Por qué
no galleta?
Explica el por qué de las cosas, por ejemplo, necesitar un abrigo cuandohace frío
Compara cosas usando palabras como “más grande” o “más corto" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Nombra por lo menos un color ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Intenta hacer que usted lo mire diciendo “Mírame” ∙ ∙ ∙ ∙ ∙
Dice su primer nombre cuando se lo preguntan ∙ ∙ ∙ ∙ ∙ ∙
Dibuja líneas ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Cuando él o ella habla, los demás lo entienden la mayoría del tiempo ∙
Se lava y se seca las manos sin ayuda (incluso si usted abre el agua) ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 30 meses 29 meses, 0 días to 34 meses, 31 días
29 months, 0 days to 34 months, 31 days
V1.07, 4/1/17
∙
∙
∙
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Usa palabras como “ayer” y “mañana” correctamente ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙Cuando él o ella habla, los demás lo entienden la mayoría del tiempo
Se lava y se seca las manos sin ayuda (incluso si usted abre el agua)
∙
∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Explica el por qué de las cosas, por ejemplo, necesitar un abrigo cuandohace frío
Compara cosas usando palabras como “más grande” o “más corto" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Contesta preguntas como “¿Qué haces cuando tienes frío?” o “¿…cuando
tienes sueño?
Cuenta una historia de un libro o de la televisión ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Dibuja formas sencillas – por ejemplo, un círculo o un cuadrado ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Dice palabras en plural como “peces” para más de un pez y “lápices” para
más de un lápiz
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Hace preguntas que empiezan con “por qué” o “cómo” – por ejemplo “¿Por qué
no galleta?
Pautas Madurativas: 36 meses 35 meses, 0 días to 46 meses, 31 días
35 months, 0 days to 46 months, 31 days
V1.07, 4/1/17
∙
∙
∙
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Dibuja cosas que usted puede reconocer ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Compara cosas usando palabras como “más grande” o “más corto" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Contesta preguntas como “¿Qué haces cuando tienes frío?” o “¿…cuando
tienes sueño?
Dibuja formas sencillas – por ejemplo, un círculo o un cuadrado ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Dice palabras en plural como “peces” para más de un pez y “lápices” para
más de un lápiz
Usa palabras como “ayer” y “mañana” correctamente ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Permanece seco durante toda la noche (no se orina en la cama) ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sigue reglas sencillas cuando juega juegos de mesa o con cartas ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Escribe su nombre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Cuenta una historia de un libro o de la televisión ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas: 48 meses 47 meses, 0 días to 58 meses, 31 días
47 months, 0 days to 58 months, 31 days
V1.07, 4/1/17
∙
∙
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
Todavía No Algunas Veces Mucho
Cuenta una historia de un libro o de la televisión ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Dibuja formas sencillas – por ejemplo, un círculo o un cuadrado ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Usa palabras como “ayer” y “mañana” correctamente ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Permanece seco durante toda la noche (no se orina en la cama) ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Sigue reglas sencillas cuando juega juegos de mesa o con cartas ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Nombra los días de la semana en el orden correcto ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Escribe su nombre ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Dibuja cosas que usted puede reconocer ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Colorea dentro de las líneas ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pautas Madurativas (Developmental Milestones)
Estas preguntas son acerca del desarrollo de su niño/a. Cuando nosotros decimos desarrollo nos referimos a cosas como gatear, caminar, jugar y hablar. Nosotros queremos tener una idea de que tan frecuente su niño/a hace cada una de estas cosas. Para cada pregunta, díganos si su niño/a todavía no lo hace, lo hace algunas veces o si él/ella lo hace mucho.
Dice palabras como “peces” para más de un pez y “lápices” para más de un
lápiz
Pautas Madurativas: 60 meses 59 meses, 0 días to 65 meses, 31 días
59 months, 0 days to 65 months, 31 days
V1.07, 4/1/17
∙
© 2010 Tufts Medical Center, Inc. All rights reserved.
Nombre del Niño/a:(Child's name)
Fecha de Nacimiento (Mes/Día/Año):(Date of birth)
Fecha de Hoy:(Today's Date)
************ Please continue on the back ************
Not at all Somewhat Very Much
PARENT'S CONCERNSNot At All Somewhat Very Much
© 2010, Tufts Medical Center, Inc. All rights reserved.
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙
∙ ∙ ∙ ∙ ∙∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙ ∙ Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙
Keeps head steady when held in a sitting position Makes sounds like "ga," "ma," or "ba" ∙ ∙ ∙ Looks when you call his or her name ∙ ∙ ∙ ·
∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very MuchMakes sounds that let you know he or she is happy or upset ∙ ∙ ∙Seems happy to see you ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Do you have any concerns about your child's learning or development?
Do you have any concerns about your child's behavior?
Follows a moving toy with his or her eyes ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ Turns head to find the person who is talking ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ Holds head steady when being pulled up to a sitting position ∙ ∙ ∙Brings hands together ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ Laughs ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
TM
SWYC: 2 months1 months, 0 days to 3 months, 31 days V1.08, 9/1/19
Yes
1 23
6
7
EMOTIONAL CHANGES WITH A NEW BABY**
As much as I always Not quite so Definitely not so Not at all could much now much now
2 I have looked forward with enjoyment to things As much as I ever did Rather less than I Definitely less than I Hardly at all
used to used to
3* I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never
4 I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often
5* I have felt scared or panicky for no good reason Yes, quite a lot Yes, sometimes No, not much No, not at all
6* Things have been getting on top of me Yes, most of the time I Yes, sometimes I No, most of the
haven't been able to haven't been coping as time I have coped No, I have
been coping as well as ever
cope at all well as usual quite well
7* I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all
8* I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all
9* I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never
10* The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never
Since you have a new baby in your family, we would like to know how you are feeling now. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
In the past seven days…1 I have been able to laugh and see the funny side of things
Does anyone who lives with your child smoke tobacco?In the last year, have you ever drunk alcohol or used drugs more than you meant to?Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
4 Has a family member's drinking or drug use ever had a bad effect on your child?
**© 1987 The Royal College of Psychiatrists. Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium).
FAMILY QUESTIONS
Great difficulty
Some difficulty
No difficulty
A lot of tension
Some tension
No tension
In general, how would you describe your relationship with your spouse/partner?
Do you and your partner work out arguments with:
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
No
5 Within the past 12 months, we worried whether our food would run out before we got money to buy more.
Often trueNever true Sometimes true
8 During the past week, how many days did you or
other family members read to your child?
Not applicable
Not applicable
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
Not at all Somewhat Very Much0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
Not at all Somewhat Very Much
⃝Do you have any concerns about your child's learning or development?Do you have any concerns about your child's behavior?
⃝
PARENT'S CONCERNS
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)
These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
DEVELOPMENTAL MILESTONES
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Holds head steady when being pulled up to a sitting position ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Brings hands together ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Laughs ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Keeps head steady when held in a sitting position ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Makes sounds like "ga," "ma," or "ba" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks when you call his or her name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Rolls over ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Passes a toy from one hand to the other ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks for you or another caregiver when upset ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Holds two objects and bangs them together ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Very MuchSomewhatNot Yet
∙
∙∙
∙
∙
∙ ∙
∙
∙
∙ ∙
∙ ∙
∙
∙
Child's Name:
Birth Date:
Today's Date:
⃝⃝
⃝⃝
© 2010, Tufts Medical Center, Inc. All rights reserved.
************ Please continue on the back ************
TM
SWYC:4 months 4 months, 0 days to 5 months, 31 days V1.08, 9/1/19
Yes
1 23
6
7
EMOTIONAL CHANGES WITH A NEW BABY**
As much as I always Not quite so Definitely not so Not at all could much now much now
2 I have looked forward with enjoyment to things As much as I ever did Rather less than I Definitely less than I Hardly at all
used to used to
3* I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never
4 I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often
5* I have felt scared or panicky for no good reason Yes, quite a lot Yes, sometimes No, not much No, not at all
6* Things have been getting on top of me Yes, most of the time I Yes, sometimes I No, most of the
haven't been able to haven't been coping as time I have coped No, I have
been coping as well as ever
cope at all well as usual quite well
7* I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all
8* I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all
9* I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never
10* The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never
Since you have a new baby in your family, we would like to know how you are feeling now. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
In the past seven days…1 I have been able to laugh and see the funny side of things
Does anyone who lives with your child smoke tobacco?In the last year, have you ever drunk alcohol or used drugs more than you meant to?Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
4 Has a family member's drinking or drug use ever had a bad effect on your child?
**© 1987 The Royal College of Psychiatrists. Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium).
FAMILY QUESTIONS
Great difficulty
Some difficulty
No difficulty
A lot of tension
Some tension
No tension
In general, how would you describe your relationship with your spouse/partner?
Do you and your partner work out arguments with:
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
No
5 Within the past 12 months, we worried whether our food would run out before we got money to buy more.
Often trueNever true Sometimes true
Not applicable
Not applicable
8 During the past week, how many days did you or other family members read to your child?
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
Not at all Somewhat Very Much0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
0 1 2
Not at all Somewhat Very Much
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)
These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
DEVELOPMENTAL MILESTONES
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Makes sounds like "ga," "ma," or "ba" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks when you call his or her name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Rolls over ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Passes a toy from one hand to the other ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks for you or another caregiver when upset ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Holds two objects and bangs them together ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Holds up arms to be picked up ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Gets into a sitting position by him or herself ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Picks up food and eats it ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pulls up to standing ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Very MuchSomewhatNot Yet
PARENT'S CONCERNS
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Do you have any concerns about your child's learning or development? ⃝ ⃝ ⃝
Do you have any concerns about your child's behavior? ⃝ ⃝ ⃝
Child's Name:
Birth Date:
Today's Date:
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
∙
© 2010, Tufts Medical Center, Inc. All rights reserved.
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TM
SWYC: 6 months 6 months, 0 days to 8 months, 31 days V1.08, 9/1/19
Yes
1 23
6
7
EMOTIONAL CHANGES WITH A NEW BABY**
As much as I always Not quite so Definitely not so Not at all could much now much now
2 I have looked forward with enjoyment to things As much as I ever did Rather less than I Definitely less than I Hardly at all
used to used to
3* I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never
4 I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often
5* I have felt scared or panicky for no good reason Yes, quite a lot Yes, sometimes No, not much No, not at all
6* Things have been getting on top of me Yes, most of the time I Yes, sometimes I No, most of the
haven't been able to haven't been coping as time I have coped No, I have
been coping as well as ever
cope at all well as usual quite well
7* I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all
8* I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all
9* I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never
10* The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never
Since you have a new baby in your family, we would like to know how you are feeling now. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
In the past seven days…1 I have been able to laugh and see the funny side of things
Does anyone who lives with your child smoke tobacco?In the last year, have you ever drunk alcohol or used drugs more than you meant to?Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
4 Has a family member's drinking or drug use ever had a bad effect on your child?
**© 1987 The Royal College of Psychiatrists. Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. Written permission must be obtained from the Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium).
FAMILY QUESTIONS
Great difficulty
Some difficulty
No difficulty
Do you and your partner work out arguments with:
A lot of tension
Some tension
No tension
In general, how would you describe your relationship with your spouse/partner?
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
No
5 Within the past 12 months, we worried whether our food would run out before we got money to buy more.
Often trueNever true Sometimes true
Not applicable
Not applicable
8 During the past week, how many days did you or
other family members read to your child?
Not at all Somewhat Very Much
Picks up food and eats it ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pulls up to standing ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Holds up arms to be picked up ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
ets into a sitting position by him or herself ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
Plays games like "peek a boo" or "pat a cake" ∙ ∙ ∙ ∙ ∙ ∙ ∙
Calls you "mama" or "dada" or similar name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that you make ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks across a room without help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Follows directions like "Come here" or " ive me the ball" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙
Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
∙ ∙
© 1
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TM
SWYC: 9 months 9 months, 0 days to 11 months, 31 days V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
Not at all Somewhat Very Much
Plays games like "peek a boo" or "pat a cake" ∙ ∙ ∙ ∙ ∙ ∙ ∙
Calls you "mama" or "dada" or similar name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Picks up food and eats it ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Pulls up to standing ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that you make ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks across a room without help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Follows directions like "Come here" or " ive me the ball" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Runs ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks up stairs with help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙
Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
∙
© 1
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TM
SWYC: 12 months 12 months, 0 days to 14 months, 31 days V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
10
Copies sounds that you make ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks across a room without help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Not at all Somewhat Very Much
Calls you "mama" or "dada" or similar name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
Follows directions like "Come here" or " ive me the ball" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Runs ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks up stairs with help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Kicks a ball ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least familiar ob ects like ball or milk ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least body parts like nose, hand, or tummy ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child mind being held by other people? ∙ ∙ ∙ ∙ ∙
Does your child cry a lot? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time in new places? ∙ ∙ ∙ ∙ ∙
Does your child have trouble staying asleep? ∙ ∙ ∙ ∙ ∙
Is it hard to keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙
Is it hard to put your child to sleep? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to get enough sleep because of your child? ∙ ∙ ∙ ∙ ∙
Is it hard to comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙
Is your child fussy or irritable? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child have a hard time being with new people? ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
∙ ∙
© 1
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TM
SWYC: 15 months 15 months, 0 days to 17 months, 31 days V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
Not at all Somewhat Very Much
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
Is your child… Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Kicks a ball ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least familiar ob ects like ball or milk ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Does your child... Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least body parts like nose, hand, or tummy ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Climbs up a ladder at a playground ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
ses words like "me" or "mine" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Runs ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Walks up stairs with help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
umps off the ground with two feet ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Puts 2 or more words together like "more water" or "go outside" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
ses words to ask for help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to… Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Child's Name:
Birth Date:
Today's Date:
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© 1
TM
SWYC: 18 months 18 months, 0 days to 22 months, 31 days V1.08, 9/1/19
8
9
What are your child's favorite play activities?
Playing with dolls or
stuffed animals
Reading books with
you
Climbing, running and being active
Lining up toys or other
things
Watching things go round and
round like fans or wheels
(please check all that apply)
How does your child usually show you something he or she wants?
Says a word for what he
or she wants
Points to it with one
finger
Reachesfor it
Pulls me over or puts my hand on it
Grunts, cries or screams
Is your child interested in playing with other children?When you say a word or wave your hand, will your child try to copy you?Does your child look at you when you call his or her name?Does your child look if you point to something across the room?
Always Usually Sometimes Rarely Never
PARENT'S OBSERVATIONS OF SOCIAL INTERACTIONS (POSI)
Does your child bring things to you to show them to you?
Many times a day
A few times a day
A few times a week
Less than once a week Never
FAMILY QUESTIONS
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
1 Does anyone who lives with your child smoke tobacco?2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?3 Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?4 Has a family member's drinking or drug use ever had a bad effect on your child?
Not at all Severaldays
More than half the days
Nearly every dayOver the past two weeks, how often have you been bothered by any of the following problems?6 Having little interest or pleasure in doing things?7 Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficultyGreat
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
For acknowledgments, validation, and other information concerning the POSI, please see www.theswyc.org/posi
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
(please check all that apply)
Not at all Somewhat Very Much
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child… Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child... Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
Is it hard to… Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Says his or her first name when asked ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Draws lines ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Tries to get you to watch by saying "Look at me" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Puts 2 or more words together like "more water" or "go outside" ∙ ∙
ses words to ask for help ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least one color ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONES
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
ses words like "me" or "mine" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
umps off the ground with two feet ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least body parts like nose, hand, or tummy ∙ ∙ ∙ ∙ ∙
Climbs up a ladder at a playground ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
************ Please continue on the back ************
© 2010, Tufts Medical Center, Inc. All rights reserved.
TM
SWYC: 24 months 23 months, 0 days to 28 months, 31 days V1.08, 9/1/19
8
9
What are your child's favorite play activities?
Playing with dolls or
stuffed animals
Reading books with
you
Climbing, running and being active
Lining up toys or other
things
Watching things go round and
round like fans or wheels
(please check all that apply)
How does your child usually show you something he or she wants?
Says a word for what he
or she wants
Points to it with one
finger
Reachesfor it
Pulls me over or puts my hand on it
Grunts, cries or screams
Is your child interested in playing with other children?When you say a word or wave your hand, will your child try to copy you?Does your child look at you when you call his or her name?Does your child look if you point to something across the room?
Always Usually Sometimes Rarely Never
PARENT'S OBSERVATIONS OF SOCIAL INTERACTIONS (POSI)
Does your child bring things to you to show them to you?
Many times a day
A few times a day
A few times a week
Less than once a week Never
FAMILY QUESTIONS
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
1 Does anyone who lives with your child smoke tobacco?2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?3 Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?4 Has a family member's drinking or drug use ever had a bad effect on your child?
Not at all Severaldays
More than half the days
Nearly every dayOver the past two weeks, how often have you been bothered by any of the following problems?6 Having little interest or pleasure in doing things?7 Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficultyGreat
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
For acknowledgments, validation, and other information concerning the POSI, please see www.theswyc.org/posi
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
(please check all that apply)
Not at all Somewhat Very Much
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child… Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child... Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
Is it hard to… Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Compares things using words like "bigger" or "shorter" ∙ ∙ ∙ ∙ ∙
Answers questions like "What do you do when you are cold?" or " when you are sleepy?"
xplains the reasons for things, like needing a sweater when it's cold ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Talks so other people can understand him or her most of the time ∙ ∙
Washes and dries hands without help even if you turn on the water ∙Asks questions beginning with "why" or "how" like "Why no cookie?" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONESMost children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
Says his or her first name when asked ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Draws lines ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names at least one color ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Tries to get you to watch by saying "Look at me" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Child's Name:
Birth Date:
Today's Date:
∙ ∙
************ Please continue on the back ************© 1
TM
SWYC: 30 months 29 months, 0 days to 34 months, 31 days V1.08, 9/1/19
8
9
What are your child's favorite play activities?
Playing with dolls or
stuffed animals
Reading books with
you
Climbing, running and being active
Lining up toys or other
things
Watching things go round and
round like fans or wheels
(please check all that apply)
How does your child usually show you something he or she wants?
Says a word for what he
or she wants
Points to it with one
finger
Reachesfor it
Pulls me over or puts my hand on it
Grunts, cries or screams
Is your child interested in playing with other children?When you say a word or wave your hand, will your child try to copy you?Does your child look at you when you call his or her name?Does your child look if you point to something across the room?
Always Usually Sometimes Rarely Never
PARENT'S OBSERVATIONS OF SOCIAL INTERACTIONS (POSI)
Does your child bring things to you to show them to you?
Many times a day
A few times a day
A few times a week
Less than once a week Never
FAMILY QUESTIONS
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
1 Does anyone who lives with your child smoke tobacco?2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?3 Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?4 Has a family member's drinking or drug use ever had a bad effect on your child?
Not at all Severaldays
More than half the days
Nearly every dayOver the past two weeks, how often have you been bothered by any of the following problems?6 Having little interest or pleasure in doing things?7 Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficultyGreat
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
For acknowledgments, validation, and other information concerning the POSI, please see www.theswyc.org/posi
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
(please check all that apply)
Not t Some t er
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
s o r i Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
oes o r i Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
s it r to Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Says words like "feet" for more than one foot and "men" for more than one man
ses words like "yesterday" and "tomorrow" correctly ∙ ∙ ∙ ∙ ∙
Draws simple shapes like a circle or a square ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Compares things using words like "bigger" or "shorter" ∙ ∙ ∙ ∙ ∙
Answers questions like "What do you do when you are cold?" or " when you are sleepy?"Tells you a story from a book or tv ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not et Some t er
Asks questions beginning with "why" or "how" like "Why no cookie?" ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
xplains the reasons for things, like needing a sweater when it's cold ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Talks so other people can understand him or her most of the time ∙ ∙ ∙ ∙
Washes and dries hands without help even if you turn on the water ∙
DEVELOPMENTAL MILESTONES
Child's Name:
Birth Date:
Today's Date:
∙ ∙ ∙ ∙ ∙ ∙ ∙∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙
e se o ti e o t e © 1
TM
S mo t s
mo t s s to mo t s s V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
10
Not t Some t er
Tells you a story from a book or tv ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Draws simple shapes like a circle or a square ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Compares things using words like "bigger" or "shorter" ∙ ∙ ∙ ∙ ∙ ∙
Answers questions like "What do you do when you are cold?" or " when you are sleepy?"
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not et Some t er
Follows simple rules when playing a board game or card game ∙ ∙
Says words like "feet" for more than one foot and "men" for more than one man
ses words like "yesterday" and "tomorrow" correctly ∙ ∙ ∙ ∙ ∙
Stays dry all night ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
s it r to Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Prints his or her name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Draws pictures you recogni e ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
oes o r i Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
s o r i Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONES
Child's Name:
Birth Date:
Today's Date:
∙ ∙ ∙ ∙ ∙ ∙ ∙
∙ ∙
∙ ∙ ∙ ∙ ∙ ∙ ∙
e se o ti e o t e © 1
TM
S mo t s
mo t s s to mo t s s V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
10
Not at all Somewhat Very Much
Says words like "feet" for more than one foot and "men" for more than one man
ses words like "yesterday" and "tomorrow" correctly ∙ ∙ ∙ ∙ ∙
Tells you a story from a book or tv ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Draws simple shapes like a circle or a square ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Most children at this age will be able to do some (but not all) of the developmental tasks listed below. Please tell us how much your child is doing each of these things. PLEASE BE SURE TO ANSWER ALL THE QUESTIONS.
Not Yet Somewhat Very Much
Draws pictures you recogni e ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Stays dry all night ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Follows simple rules when playing a board game or card game ∙ ∙ ∙
Prints his or her name ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is it hard to… Take your child out in public? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Stays in the lines when coloring ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Names the days of the week in the correct order ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Fidgety or unable to sit still? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Angry? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble staying with one activity? ∙ ∙ ∙ ∙ ∙
Fight with other children? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Seem sad or unhappy? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
et upset if things are not done in a certain way? ∙ ∙ ∙ ∙ ∙
Have a hard time with change? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble playing with other children? ∙ ∙ ∙ ∙ ∙ ∙
Break things on purpose? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)These questions are about your child's behavior. Think about what you would expect of other children the same age, and tell us how much each statement applies to your child.
Does your child... Seem nervous or afraid? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Is your child… Aggressive? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have trouble paying attention? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Have a hard time calming down? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Comfort your child? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Know what your child needs? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
Keep your child on a schedule or routine? ∙ ∙ ∙ ∙ ∙ ∙
et your child to obey you? ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙
DEVELOPMENTAL MILESTONES
Child's Name:
Birth Date:
Today's Date:
∙ ∙ ∙ ∙ ∙ ∙ ∙
************ Please continue on the back ************
© 1
TM
SWYC: 60 months 59 months, 0 days to 65 months, 31 days V1.08, 9/1/19
34 Has a family member's drinking or drug use ever had a bad effect on your child?
6 Having little interest or pleasure in doing things?7
8
9
FAMILY QUESTIONS
1 Does anyone who lives with your child smoke tobacco?
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Yes No
Because family members can have a big impact on your child's development, please answer a few questions about your family below:
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Over the past two weeks, how often have you been bothered by any of the following problems? Not at all Several
daysMore than
half the days Nearly every day
Feeling down, depressed, or hopeless?
In general, how would you describe your relationship with your spouse/partner?
No tension
Some tension
A lot of tension
Not applicable
Do you and your partner work out arguments with:No
difficulty Some
difficulty Great
difficultyNot applicable
Do you have any concerns about your child's behavior?
PARENT'S CONCERNSNot At All Somewhat Very Much
Do you have any concerns about your child's learning or development?
Within the past 12 months, we worried whether our food would
run out before we got money to buy more.
Never Sometimes Often
10