SWYC: 4 months

SWYC: 4 months

4 months, 0 days to 5 months, 31 days
Child's Name:*
Birth Date:*

MonthDayYear
Date
Today's Date:*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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*

Not YetSomewhatVery Much
Brings hands together*

Not YetSomewhatVery Much
Laughs*

Not YetSomewhatVery Much
Keeps head steady when held in a sitting position*

Not YetSomewhatVery Much
Makes sounds like "ga," "ma," or "ba"*

Not YetSomewhatVery Much
Looks when you call his or her name*

Not YetSomewhatVery Much
Rolls over*

Not YetSomewhatVery Much
Passes a toy from one hand to the other*

Not YetSomewhatVery Much
Looks for you or another caregiver when upset*

Not YetSomewhatVery Much
Holds two objects and bangs them together*

Not YetSomewhatVery Much
Developmental Milestones Total:
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 allSomewhatVery Much
Does your child have a hard time in new places?*

Not at allSomewhatVery Much
Does your child have a hard time with change?*

Not at allSomewhatVery Much
Does your child mind being held by other people?*

Not at allSomewhatVery Much
Does your child cry a lot?*

Not at allSomewhatVery Much
Does your child have a hard time calming down?*

Not at allSomewhatVery Much
Is your child fussy or irritable?*

Not at allSomewhatVery Much
Is it hard to comfort your child?*

Not at allSomewhatVery Much
Is it hard to keep your child on a schedule or routine?*

Not at allSomewhatVery Much
Is it hard to put your child to sleep?*

Not at allSomewhatVery Much
Is it hard to get enough sleep because of your child?*

Not at allSomewhatVery Much
Does your child have trouble staying asleep?*

Not at allSomewhatVery Much
Baby Pediatric Symptom Checklist (BPSC) Total:
PARENT'S CONCERNS
Do you have any concerns about your child's learning or development?*

Not at allSomewhatVery Much
Do you have any concerns about your child's behavior?*

Not at allSomewhatVery 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:
Does anyone who lives with your child smoke tobacco?*

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

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

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

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

Never trueSometimes trueOften true
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…
I have been able to laugh and see the funny side of things*

As much as I always couldNot quite so much nowDefinitely not so much nowNot at all
I have looked forward with enjoyment to things*

As much as I ever didRather less than I used toDefinitely less than I used toNot at all
I have blamed myself unnecessarily when things went wrong*

Yes, most of the timeYes, some of the timeNot very oftenNo, never
I have been anxious or worried for no good reason*

No, not at allHardly everYes, sometimesYes, very often
I have felt scared or panicky for no good reason*

Yes, quite a lotYes, sometimesNo, not muchNo, not at all
Things have been getting on top of me*

Yes, most of the time I haven't been able to cope at allYes, sometimes I haven't been coping as well as usualNo, most of the time I have coped quite wellNo, I have been coping as well as ever
I have been so unhappy that I have had difficulty sleeping*

Yes, most of the timeYes, sometimesNot very oftenNo, not at all
I have felt sad or miserable*

Yes, most of the timeYes, quite oftenNot very oftenNo, not at all
I have been so unhappy that I have been crying*

Yes, most of the timeYes, quite oftenOnly occasionallyNo, never
The thought of harming myself has occurred to me*

Yes, quite oftenSometimesHardly everNever
Parental Concerns:
Tobacco Use in Home:
Substance Abuse in Home:
Food Insecurity:
EMOTIONAL CHANGES WITH A NEW BABY TOTAL:
Age in Months:
Should be Empty:

SWYC: 4 months

DEVELOPMENTAL MILESTONES

BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)

PARENT'S CONCERNS

FAMILY QUESTIONS

EMOTIONAL CHANGES WITH A NEW BABY

In the past seven days…