TM

SWYC: Child's Name:

2 months Birth Date:

1 months, 0 days to 3 months, 31 days
Today's Date:
V1.08, 9/1/19

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.
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 ∙ ∙ ∙ · ∙ ∙ ∙ ∙ ∙ ∙   

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.
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? ∙ ∙ ∙ ∙ ∙ ∙ ∙   

PARENT'S CONCERNS
Not At All Somewhat Very Much
Do you have any concerns about your child's learning or
development?   

Do you have any concerns about your child's behavior?   

© 2010, Tufts Medical Center, Inc. All rights reserved.

************ Please continue on the back ************

FAMILY QUESTIONS
Because family members can have a big impact on your child's development, please answer a few questions
about your family below:
Yes No
1 Does anyone who lives with your child smoke tobacco?  
2 In the last year, have you ever drunk alcohol or used drugs more than you meant to?  
3 Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?  
4 Has a family member's drinking or drug use ever had a bad effect on your child?  
Never true Sometimes true Often true
5 Within the past 12 months, we worried whether our food would
run out before we got money to buy more.   

In general, how would you describe your Some A lot of

6 No tension tension tension Not applicable
relationship with your spouse/partner? 
  
Some Great Not applicable
No difficulty difficulty difficulty
7 Do you and your partner work out arguments with:    

8 During the past week, how many days did you or

other family members read to your child?        
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…
1 I have been able to laugh and see the funny side of things
 As much as I always  Not quite so  Definitely not so  Not at all
could much now much now
2 I have looked forward with enjoyment to things
 As much as I ever did  Rather less than I Definitely less than I  Hardly at all
used to used to
3* I have blamed myself unnecessarily when things went wrong
 Yes, most of the time  Yes, some of the time  Not very often  No, never
4 I have been anxious or worried for no good reason
 No, not at all  Hardly ever  Yes, sometimes  Yes, very often
5* I have felt scared or panicky for no good reason
 Yes, quite a lot  Yes, sometimes  No, not much  No, not at all
6* Things have been getting on top of me
 Yes, most of the time I  Yes, sometimes I  No, most of the  No, I have
been coping
haven't been able to haven't been coping as time I have coped
as well as ever
cope at all well as usual quite well
7* I have been so unhappy that I have had difficulty sleeping
 Yes, most of the time  Yes, sometimes  Not very often  No, not at all
8* I have felt sad or miserable
 Yes, most of the time  Yes, quite often  Not very often  No, not at all
9* I have been so unhappy that I have been crying
 Yes, most of the time  Yes, quite often  Only occasionally  No, never
10* The thought of harming myself has occurred to me
 Yes, quite often  Sometimes  Hardly ever  Never
**© 1987 The Royal College of Psychiatrists. Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of
the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. Written permission must be obtained from the
Royal College of Psychiatrists for copying and distribution to others or for republication (in print, online or by any other medium).