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.

Makes sounds like "ga," "ma," or "ba" * Looks when you call his or her name * Rolls over * Passes a toy form 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 *

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. * 6. In general, how would you describe your relationship with your spouse/partner? * 7. Do you and your partner work out arguments with: * 8. During the past week, how many days did you or other family members read to your child?

Emotional Changes With A New Baby**

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 * 2. I have looked forward with enjoyment to things * 3. I have blamed myself unnecessarily when things went wrong * 4. I have been anxious or worried for no good reason * 5. I have felt scared or panicky for no good reason * 6. Things have been getting on top of me * 7. I have been so unhappy that I have had difficulty sleeping * 8. I have felt sad or miserable * 9. I have been so unhappy that I have been crying * 10. The thought of harming myself has occurred to me *