SWYC: 24 months
23 months, 0 days to 28 months, 31 days
Child's Name:
*
Birth Date:
*
-
Month
-
Day
Year
Date
Today's Date:
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Names at least body parts - like nose, hand, or tummy
*
Not Yet
Somewhat
Very Much
Climbs up a ladder at a playground
*
Not Yet
Somewhat
Very Much
Uses words like "me" or "mine"
*
Not Yet
Somewhat
Very Much
Jumps off the ground with two feet
*
Not Yet
Somewhat
Very Much
Puts 2 or more words together - like "more water" or "go outside"
*
Not Yet
Somewhat
Very Much
Uses words to ask for help
*
Not Yet
Somewhat
Very Much
Names at least one color
*
Not Yet
Somewhat
Very Much
Tries to get you to watch by saying "Look at me"
*
Not Yet
Somewhat
Very Much
Says his or her first name when asked
*
Not Yet
Somewhat
Very Much
Draws lines
*
Not Yet
Somewhat
Very Much
Developmental Milestones Total:
PRESCHOOL PEDIATRIC SYMPTOM CHECKLIST (PPSC)
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 seem nervous or afraid?
*
Not at all
Somewhat
Very Much
Does your child seem sad or unhappy?
*
Not at all
Somewhat
Very Much
Does your child get upset if things are not done in a certain way?
*
Not at all
Somewhat
Very Much
Does your child have a hard time with change?
*
Not at all
Somewhat
Very Much
Does your child have trouble playing with other children?
*
Not at all
Somewhat
Very Much
Does your child break things on purpose?
*
Not at all
Somewhat
Very Much
Does your child fight with other children?
*
Not at all
Somewhat
Very Much
Does your child have trouble paying attention?
*
Not at all
Somewhat
Very Much
Does your child have a hard time calming down?
*
Not at all
Somewhat
Very Much
Does your child have trouble staying with one activity?
*
Not at all
Somewhat
Very Much
Is your child aggressive?
*
Not at all
Somewhat
Very Much
Is your child fidgety or unable to sit still?
*
Not at all
Somewhat
Very Much
Is your child angry?
*
Not at all
Somewhat
Very Much
Is it hard to take your child out in public?
*
Not at all
Somewhat
Very Much
Is it hard to comfort your child?
*
Not at all
Somewhat
Very Much
Is it hard to know what your child needs?
*
Not at all
Somewhat
Very Much
Is it hard to keep your child on a schedule or routine?
*
Not at all
Somewhat
Very Much
Does your get your child to obey you?
*
Not at all
Somewhat
Very Much
Preschool Pediatric Symptom Checklist (PPSC) Total:
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:
Does anyone who lives with your child smoke tobacco?
*
Yes
No
In the last year, have you ever drunk alcohol or used drugs more than you meant to?
*
Yes
No
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
*
Yes
No
Has a family member's drinking or drug use ever had a bad effect on your child?
*
Yes
No
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
Parental Concerns:
Tobacco Use in Home:
Substance Abuse in Home:
Food Insecurity:
Age in Months:
Submit
Should be Empty: