Infancy 2

University of St. La Salle- Bacolod City We are the students of University of St. La Salle and we would like to ask your help regarding our project on infancy. This questionnaire serves as a basis for the project of BSN 3 students in connection with their lesson in infancy in NCM. I hope you would be kind and considerate in answering the questions truthfully. God bless. Thank you. Name of Mother: Name of Baby: No. of Siblings: ____

Age:__ Age:__

Baby’s Information Baby’s Birthdate:__________________ Birth Weight:____________________ Birth Height:_____________________ Type of Delivery: ___ Normal ____ Caesarian

Latest Weight: ______ Latest Height: _______ Latest Head circumference: ______ Latest Chest circumference: ____

Milk: ___ Breastfeed __Formula Milk ___Both Foods: ___cerelac ______ gerber others: (specify)________________________________ Does your baby… 1. Roll over both ways? 2. Sit up? 3. Reach for objects in hand? 4. Transfer objects from one hand to the other? 5. Crawls? 6. Walks? 7. Able to see things clearly? 8. Uses voice to express joy and pleasure? 9. Recognizes his parents? 10. Babbles consonants? (ex. Bababa) 11. Afraid/ fear of strangers? 12. Distinguish emotions especially when being scolded or angry? 13. Enjoys playing peek-a-boo? 14. Struggle to get objects out? 15. Sits alone with support? 16. Sits alone without support?

YES NO Does your baby… 17. Learns to drink from cup? 18. Fear of being left behind by parents? 19. Imitate what others do? (ex. Copies sounds, actions, etc) 20. Says first words? 21. Follows simple instructions? 22. Responds to his name when called? 23. Enjoys toys like rattles? 24. Holds bottle well? 25. Eats finger foods?

YES

NO

Please check those that are applicable to your baby: ____ Teething ____ Thumb Sucking ____ Use of Pacifiers ____ Head Banging ____ Sleep Problems (e.g. insomia) ____ Constipation ____ Loose Stools ( e.g. diarrhea) ____ Colic (e.g. stomachache) ____ Spitting up (e.g. uha) ____ Diaper rashes ____ Diaper infection ____ Falls ____ Animal Bites ____ Burns ____ Suffocation Was there an instance that the baby was hospitalized? Yes or no? _______ If yes? When? ________________________ Why? (for what reason) _____________________________________________________________________________ _____________________________________________________________________________ __ Any congenital problems: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ___