SWYC: 12 months

SWYC: 12 months

12 months, 0 days to 14 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.
Picks up food and eats it*

Not YetSomewhatVery Much
Pulls up to standing*

Not YetSomewhatVery Much
Plays games like "peek-a-boo" or "pat-a-cake"*

Not YetSomewhatVery Much
Calls you "mama" or "dada" or similar name*

Not YetSomewhatVery Much
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"*

Not YetSomewhatVery Much
Copies sounds that you make*

Not YetSomewhatVery Much
Walks across a room without help*

Not YetSomewhatVery Much
Follows directions - like "Come here" or "Give me the ball"*

Not YetSomewhatVery Much
Runs*

Not YetSomewhatVery Much
Walks up stairs with help*

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
Parental Concerns:
Tobacco Use In Home:
Substance Abuse in Home:
Food Insecurity:
Age in Months:
Should be Empty:

SWYC: 12 months

DEVELOPMENTAL MILESTONES

BABY PEDIATRIC SYMPTOM CHECKLIST (BPSC)

PARENT'S CONCERNS

FAMILY QUESTIONS