SWYC

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Survey of Well-Being of Young Children (SWYB)
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age in Months (rounded down)*
Enter your child's age in months, without going over their actual age. For example, if your child is a week away from their first birthday, you will enter "11".

Developmental Milestones (1-2 months)

1 months, 0 days to 3 months, 31 days

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.*

Rows	Not yet	Somewhat	Very much
Makes sounds that let you know he or she is happy or upset
Seems happy to see you
Follows a moving toy with his or her eyes
Turns head to find the person who is talking
Holds head steady when being pulled up to a sitting position
Brings hands together
Laughs
Keeps head steady when held in a sitting position
Makes sounds like "ga," "ma," or "ba"
Looks when you call his or her name

Score DM-2*
Developmental Milestones (4 months)

4 months, 0 days to 5 months, 31 days

Rows	Not yet	Somewhat	Very much
Holds head steady when being pulled up to a sitting position
Brings hands together
Laughs
Keeps head steady when held in a sitting position
Makes sounds like "ga," "ma," or "ba"
Looks when you call his or her name
Rolls over
Passes a toy from one hand to the other
Looks for you or another caregiver when upset
Holds two objects and bangs them together

Score DM-4*
Developmental Milestones (6 months)

6 months, 0 days to 8 months, 31 days

Rows	Not yet	Somewhat	Very much
Makes sounds like "ga," "ma," or "ba"
Looks when you call his or her name
Rolls over
Passes a toy from one hand to the other
Looks for you or another caregiver when upset
Holds two objects and bangs them together
Holds arms to be picked up
Gets into a sitting position by him or herself
Picks up food and eats it
Pulls up to standing

Score DM-6*
Developmental Milestones (9 months)

9 months, 0 days to 11 months, 31 days

Rows	Not yet	Somewhat	Very much
Holds arms to be picked up
Gets into a sitting position by him or herself
Picks up food and eats it
Pulls up to standing
Plays games like "peekaboo" or "patacake"
Calls you "mama" or "dada" or similar name
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that you make
Walks across a room without help
Follows directions like "Come here" or "give me the ball"

Score DM-9*
Developmental Milestones (12 months)

12 months, 0 days to 14 months, 31 days

Rows	Not yet	Somewhat	Very much
Picks up food and eats it
Pulls up to standing
Plays games like "peekaboo" or "patacake"
Calls you "mama" or "dada" or similar name
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that you make
Walks across a room without help
Follows directions like "Come here" or "give me the ball"
Runs
Walks up stairs with help

Score DM-12*
Developmental Milestones (15 months)

15 months, 0 days to 17 months, 31 days

Rows	Not yet	Somewhat	Very much
Calls you "mama" or "dada" or similar name
Looks around when you say things like "Where's your bottle?" or "Where's your blanket?"
Copies sounds that you make
Walks across a room without help
Follows directions like "Come here" or "give me the ball"
Runs
Walks up stairs with help
Kicks a ball
Names at least 5 familiar obects like ball or milk
Names at least 5 body parts like nose, hand, or tummy

Score DM-15*
Developmental Milestones (18 months)

18 months, 0 days to 22 months, 31 days

Rows	Not yet	Somewhat	Very much
Runs
Walks up stairs with help
Kicks a ball
Names at least 5 familiar obects like ball or milk
Names at least 5 body parts like nose, hand, or tummy
Climbs up a ladder at a playground
Uses words like "me" or "mine"
Jumps off the ground with two feet
Puts 2 or more words together like "more water" or "go outside"
Uses words to ask for help

Score DM-18*
Developmental Milestones (24 months)

23 months, 0 days to 28 months, 31 days

Rows	Not yet	Somewhat	Very much
Names at least 5 body parts like nose, hand, or tummy
Climbs up a ladder at a playground
Uses words like "me" or "mine"
Jumps off the ground with two feet
Puts 2 or more words together like "more water" or "go outside"
Uses words to ask for help
Names at least one color
Tries to get you to watch by saying "Look at me"
Says his or her first name when asked
Draws lines

Score DM-24*
Developmental Milestones (30 months)

29 months, 0 days to 34 months, 31 days

Rows	Not yet	Somewhat	Very much
Names at least one color
Tries to get you to watch by saying "Look at me"
Says his or her first name when asked
Draws lines
Talks so other people can understand him or her most of the time
Washes and dries hands without help, even if you turn on the water
Asks questions beginning with "why" or "how" like "Why no cookie?"
Explains the reasons for things, like needing a sweater when it's cold
Compares things using words like "bigger" or "shorter"
Answers questions like "What do you do when you are cold?" or "...when you are sleepy?"

Score DM-30*
Developmental Milestones (36 months)

35 months, 0 days to 46 months, 31 days

Rows	Not yet	Somewhat	Very much
Talks so other people can understand him or her most of the time
Washes and dries hands without help, even if you turn on the water
Asks questions beginning with "why" or "how" like "Why no cookie?"
Explains the reasons for things, like needing a sweater when it's cold
Compares things using words like "bigger" or "shorter"
Answers questions like "What do you do when you are cold?" or "...when you are sleepy?"
Tells you a story from a book or TV
Draws simple shapes like a circle or a square
Says words like "feet" for more than one foot, and "men" for more than one man
Uses words like "yesterday" and "tomorrow" correctly

Score DM-36*
Developmental Milestones (48 months)

47 months, 0 days to 58 months, 31 days

Rows	Not yet	Somewhat	Very much
Compares things using words like "bigger" or "shorter"
Answers questions like "What do you do when you are cold?" or "...when you are sleepy?"
Tells you a story from a book or TV
Draws simple shapes like a circle or a square
Says words like "feet" for more than one foot, and "men" for more than one man
Uses words like "yesterday" and "tomorrow" correctly
Stays dry all night
Follows simple rules when playing a board game or card game
Prints his or her name
Draws pictures you recognize

Score DM-48*
Developmental Milestones (60 months)

59 months, 0 days to 65 months, 31 days

Rows	Not yet	Somewhat	Very much
Tells you a story from a book or TV
Draws simple shapes like a circle or a square
Says words like "feet" for more than one foot, and "men" for more than one man
Uses words like "yesterday" and "tomorrow" correctly
Stays dry all night
Follows simple rules when playing a board game or card game
Prints his or her name
Draws pictures you recognize
Stays in the lines when coloring
Names the days of the week in the correct order

Score DM-60*
Dev Milestone Score*

Baby Pediatric Symptom Checklist

1 month, 0 days to 17 months, 31 days

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.*

Rows	Not at all	Somewhat	Very much
Does your child have a hard time being with new people?
Does your child have a hard time in new places?
Does your child have a hard time with change?
Does your child mind being held by other people?
Does your child cry a lot?
Does your child have a hard time calming down?
Is your child fussy or irritable?
Is it hard to comfort your child?
Is it hard to keep your child on a schedule or routine?
Is it hard to put your child to sleep?
Is it hard to get enough sleep because of your child?
Does your child have trouble staying asleep?

Score BPSC*
Preschool Pediatric Symptom Checklist

18 months, 0 days to 65 months, 31 days

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.*

Rows	Not at all	Somewhat	Very much
Does your child seem nervous or afraid?
...seem sad or unhappy?
...get upset if things are not done in a certain way?
...have a hard time with change?
...have trouble playing with other children?
...break things on purpose?
...fight with other children?
...have trouble paying attention?
...have a hard time calming down?
...have trouble staying with one activity?
Is your child aggressive?
...fidgety or unable to sit still?
...angry?
Is it hard to take your child out in public?
...comfort your child?
...know what your child needs?
...keep your child on a schedule or routine?
...get your child to obey you?

Score PPSC*
Symptom Checklist Score*

Family Questions

Because family members can have a big impact on your child's development, please answer a few questions about your family below:*

Rows	Yes	No
Does anyone who lives with your child smoke tobacco?
In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?
Has a family member's drinking or drug use ever had a bad effect on your child?

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

Never trueSometimes trueOften true

Over the past two weeks, how often have you been bothered by any of the following problems:*

Rows	Not at all	Several days	More than half the days	Nearly every day
Having little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?

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

No tensionSome tensionA lot of tensionNot applicable
Do you and your partner work out arguments with:*

No difficultySome difficultyGreat difficultyNot applicable
During the past week, how many days did you or other family members read to your child?*

Parent's Observations of Social Interactions
Does your child bring things to you to show them to you?*

Many times a dayA few times a dayA few times a weekLess than once a weekNever
Is your child interested in playing with other children?*

AlwaysUsuallySometimesRarelyNever
When you say a word or wave your hand, will your child try to copy you?*

AlwaysUsuallySometimesRarelyNever
Does your child look at you when you call his or her name?*

AlwaysUsuallySometimesRarelyNever
Does your child look if you point to something across the room?*

AlwaysUsuallySometimesRarelyNever
How does your child usually show you something he or she wants? Please check all that apply.*

Says a word for what he or she wantsPoints to it with one fingerReaches for itPulls me over or puts my hand on itGrunts, cries or screams
What are your child's favorite play activities? Please check all that apply.*

Playing with dolls or stuffed animalsReading books with youClimbing, running and being activeLining up toys or other thingsWatching things go round and round like fans or wheels

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 7 DAYS:
1. 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
2. I have looked forward with enjoyment to things*

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

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

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

Yes, quite a lotYes, sometimesNo, not muchNo, not at all
6. 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
7. I have been so unhappy that I have had difficulty sleeping*

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

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

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

Yes, quite oftenSometimesHardly everNever
EPDS Score*

Parent's Concerns

Do you have any concerns about:*

Rows	Not at all	Somewhat	Very much
Your child's learning and development?
Your child's behavior?

Should be Empty:

Survey of Well-Being of Young Children (SWYB)

Developmental Milestones (1-2 months)

Developmental Milestones (4 months)

Developmental Milestones (6 months)

Developmental Milestones (9 months)

Developmental Milestones (12 months)

Developmental Milestones (15 months)

Developmental Milestones (18 months)

Developmental Milestones (24 months)

Developmental Milestones (30 months)

Developmental Milestones (36 months)

Developmental Milestones (48 months)

Developmental Milestones (60 months)

Baby Pediatric Symptom Checklist

Preschool Pediatric Symptom Checklist

Family Questions

Parent's Observations of Social Interactions

Emotional Changes with a New Baby

Parent's Concerns