Bellevue Pediatrics

BELLEVUE PEDIATRICS

Today's Date * Child's Name * DOB *

Developmental Milestones

These questions are about your child's development. Please tell us how much your child is doing each of these things. If your child doesn't do something any more, choose the answer that describes how much he or she used to do it. Please be sure to answer ALL the questions.

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 "Give me the ball" * Runs * Walks up stairs with help * Kicks a ball * Names at least 5 familiar objects- like ball or milk * Names at least 5 body parts- like nose, hand, or tummy *

Baby Pediatrics 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? * Have a hard time in new places? * Have a hard time with change? * Mind being held by other people? * Cry a lot? * Have a hard time calming down? * Is your child fussy or irritable? *

Is it hard to .......

Comfort your child? * Keep your child on a schedule or routine? * To put your child to sleep? * Get sleep because of your child? * Does your child have trouble staying asleep? *

Parent's Concerns

Do you have any concerns about your child's learning or development? * Do you have any concerns about your child's behavior? *

Family Questions

Because family members can have a big impact of your child's development, please answer a few questions about your family below:

1. Does anyone who live with our child smoke? * 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? * 5. Within the past 12 months, we worried whether our food would run out before we got money to buy more. *

Over 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? * 8. In general, how would you describe your relationship with your spouse/partner? * 9. Do you and your partner work out arguments with: * 10. During the past week, how many days did you or other family members read to your child?