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: Age:__

Name of Baby: Age:__
No. of Siblings: ____

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… YES NO Does your baby… YES NO

1. Roll over both ways? 17. Learns to drink from cup?
2. Sit up? 18. Fear of being left behind by
parents?
3. Reach for objects in hand? 19. Imitate what others do? (ex.
Copies sounds, actions, etc)
4. Transfer objects from one hand 20. Says first words?
to the other?
5. Crawls? 21. Follows simple instructions?
6. Walks? 22. Responds to his name when
called?
7. Able to see things clearly? 23. Enjoys toys like rattles?
8. Uses voice to express joy and 24. Holds bottle well?
pleasure?
9. Recognizes his parents? 25. Eats finger foods?
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?
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:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___