Survey of Well-being of Young Children: 9 Months

Child's Name:

Birth Date:

Today's Date:

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 up arms to be picked up

Not Yet

Somewhat

Very Much

Gets into a sitting position by him or herself

Not Yet

Somewhat

Very Much

Picks up food and eats it

Not Yet

Somehwat

Vey Much

Pulls up to standing

Not Yet

Somewhat

Vey Much

Plays games like "peek-a-boo" or "pat-a-cake"

Not Yet

Somewhat

Very Much

Calls you "mama" or "dada" or similar name

Not Yet

Somewhat

Very Much

Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"

Not Yet

Somewhat

Very Much

Copies sounds that you make

Not Yet

Somewhat

Very Much

Walks across a room without help

Not Yet

Somewhat

Very Much

Follows directions - like "Come here" or "Give me the ball"

Not Yet

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.

Does your child have a hard time being with new people?

Not at all

Somewhat

Very Much

Does your child have a hard time in new places?

Not at all

Somewhat

Very Much

Does your child have a hard time with change?

Not at all

Somewhat

Very Much

Does your child mind being held by other people?

Not at all

Somewhat

Very Much

Does your child cry a lot?

Not at all

Somewhat

Very Much

Does your child have a hard time calming down?

Not at all

Somewhat

Very Much

Is your child fussy or irritable?

Not at all

Somewhat

Very Much

Is it hard to comfort your child?

Not at all

Somewhat

Very Much

Is it hard to keep your child on a schedule or routine?

Not at all

Somewhat

Very Much

Is it hard to put your child to sleep?

Not at all

Somewhat

Very Much

Is it hard to get enough sleep because of your child?

Not at all

Somewhat

Very Much

Does your child have trouble staying asleep?

Not at all

Somewhat

Very Much

PARENT'S CONCERNS

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

Not at all

Somewhat

Very Much

Do you have any concerns about your child's behavior?

Not at all

Somewhat

Very Much

FAMILY QUESTIONS

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?

Yes No

2. In the last year, have you ever drunk alcohol or used drugs more than you meant to?

Yes No

3. Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?

Yes No

4. Has a family member's drinking or drug use ever had a bad effect on your child?

Yes No

5. Within the past 12 months, we worried whether our food would run out before we got money to buy more.

Never true Sometimes true Often true

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?

Not at all

Several days

More than half the days

Nearly every day

7. Feeling down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

8. In general, how would you describe your relationship with your spouse/partner?

No tension Some tension A lot of tension Not applicable

9. Do you and your partner work out arguments with:

No tension Some tension A lot of tension Not applicable

10. During the past week, how many days did you or other family members read to your child?

0 1 2 3 4 5 6 7

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