30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
Infant ID
The 30-Month Toddler Questionnaire asks about the health, growth and development of your toddler, since completion of the 24-Month Questionnaire. If you have a set of twins, triplets or quadruplets, a separate questionnaire is included for each child, with the child's name printed on your questionnaire booklet cover. This questionnaire should take about 20-25 minutes to complete. Please try to answer each question using black or blue ink. For questions with check boxes, please place an 'X' in the box or boxes that best fit your answer. Please note that the final questions on this questionnaire refer to information we suggested you record in the Child Health Journal that we previously provided you. Prior to completing each of the questionnaires about your child (both now and in the future), it will be helpful if you have filled out the Child Health Journal first.
If you have any questions or concerns, please call our toll-free number: 1-888-870-0247 If for any reason the child whose name is listed on this questionnaire is no longer with you, please mark the box below and return the questionnaire to us so we do not contact you regarding further information about this child. PLEASE DO NOT CONTACT
Person completing the questionnaire is: (Mark all that apply using an 'X') Child's mother
Child's grandparent
Child's father
Other relative Other
START-Please tell us the date you started completing this questionnaire.
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FINISH-Please tell us the date you finished completing this questionnaire.
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Verifier's Name
Page 1 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
Questions 1-23 are about your toddler's eating and drinking habits 1. Although your child would not necessarily eat all of these foods in one day, on average how many total servings per day of the following foods does your child usually eat? Grains (such as rice, pasta, bread)
Soy food (such as tofu, soy cheese) Sweets (such as candy, cakes)
Dairy milk, yogurt or cheese
Meat (beef, poultry or pork) Potatoes Fish or seafood
Legumes (such as beans, peas, lentils)
Peanut butter (# of tablespoons per day)
Vegetables other than potatoes and legumes
Eggs (# of eggs per day)
Fruits
2. How often does your child eat from fast food restaurants like McDonald's, Kentucky Fried Chicken, Pizza Hut or Burger King? (Select one answer using an 'X') Daily
5-6 times per week
2-4 times per week
Once a week
1-3 times a month
Never
3. Does your child eat fish caught in New York State waterways? No; if no skip to question #6
Yes
4. Do you usually trim the skin and/or fat prior to cooking? No
Yes
5. On average, how many servings of fish from NYS waterways does your child consume each month? Servings per month 6. Does your child eat any of the following types of fish not caught in NYS waterways? (Mark all that apply using an 'X') Wild salmon
Tilefish
Farm raised salmon
Canned tuna in water
Sushi with tuna
Shark
Canned tuna in oil
Shrimp
Swordfish
Other shellfish
7. On average, how many servings of fish not caught in NYS waterways, does your child consume in a month? Servings per month
Page 2 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
8. Is your child currently on any of the following special diets? (Mark all that apply using an 'X') Lactose-free Diet free of lactose products
Low Sugar Eliminated or reduced sugar intake (e.g., Sugar Busters)
Gluten-free
Low Fat Eliminated or reduced fat intake
Does not consume proteins found in wheat, barley, rye and other foods
Low Calorie Eliminated or reduced calories (e.g., Weight Watchers)
Casein-free Does not consume casein protein from milk
High Protein Low Carbohydrate
High protein and/or meat intake (e.g., Atkins Diet)
Eliminated or reduced intake of carbohydrates such as bread, rice, pasta (e.g., Atkins Diet, The South Beach Diet)
Vegetarian Plant food-based diet
Vegan Plant food-based diet with no animal products
9. How much of the food eaten by your child is usually organic? (by this we mean foods produced without using insecticides, herbicides or pesticides). (Select one answer using an 'X') None
Some (less than half)
About half
Most (more than half, but not all)
All
10. During the past 7 days, how many meals did all or most of your family sit down and eat together? Meals 11. Which of the following meals does your child usually eat each day? (Mark all that apply using an 'X') Breakfast
Lunch
Dinner
12. On average, how many times per day does your child eat foods as a snack, separate from meal times?
Times per day 13. Does your child eat soil, dirt, coal or other non-food substances? (Select one answer using an 'X') No Yes 14. How would you describe your toddler's appetite on a typical day? (Select one answer using an 'X') Very good (eats all meals without fuss) Good (eats most meals without fuss) Medium (eats half meals without fuss/half meals with fuss) Poor (eats most meals with fuss) Very poor (eats all meals with fuss) Page 3 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
15. Have you sought any medical advice or treatment for your child for eating conditions, since your child was 24 months of age? No Yes
16. How often does your child do the following when given food? (mark all that apply using an 'X')
Refuses to eat a specific meal
Rarely
Sometimes
Often
Refuses to eat a specific type of food
Rarely
Sometimes
Often
Pushes food/spoon away
Rarely
Sometimes
Often
Turns head away repeatedly
Rarely
Sometimes
Often
Closes mouth when offered food
Rarely
Sometimes
Often
Can't chew solid foods
Rarely
Sometimes
Often
Gags on food
Rarely
Sometimes
Often
Holds food in mouth Spits food out
Rarely Rarely
Sometimes Sometimes
Often Often
Throws food
Rarely
Sometimes
Often
Spills food
Rarely
Sometimes
Often
Cries/screams during meals
Rarely
Sometimes
Often
17. Think about meal times with your child over the past 6 months. Please rate the following items according to how often each occurs. a. My child is willing to try new foods Never/rarely
Seldom
Occasionally
Often
At almost every meal
Often
At almost every meal
b. My child is flexible about mealtime routines Never/rarely
Seldom
Occasionally
c. My child remains seated at the table until the meal is finished Never/rarely
Seldom
Occasionally
Often
At almost every meal
d. My child displays self-injurious behavior during mealtimes (hitting self, biting self) Never/rarely
Seldom
Occasionally
Often
At almost every meal
e. My child is aggressive during mealtimes (hitting, kicking, scratching others) Never/rarely
Seldom
Occasionally
Often
At almost every meal
f. My child refuses to eat foods that require a lot of chewing (for example, child eats only soft or pureed foods) Never/rarely
Seldom
Occasionally
Often
At almost every meal
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30 Month-Toddler Questionnaire
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Upstate KIDS: The Upstate New York Infant Development Screening Program 18. Are you giving your toddler water to drink? No; if no skip to #19
Yes
18a. If yes, what is the usual source of drinking water? (Select one answer using an 'X')
21. Does your child use any Bisphenol-A-free (or BPA-free) plastic items (such as such as plastic cups, bowls, or toys)? Yes No; if no skip to # 22 Don't Know
Bottled water Tap water from a private well Tap water from the public water system
21a. If yes, what type(s) of BPA-free items are used? (Mark all that apply using an 'X') Toys Bowls/dishes
Filtered tap water (Brita or home faucet filter) Sippy cups 18b. If using filtered water, what is your water source? (Select one answer using an 'X') Private well
Public water system
19. For each of the beverages listed below, please tell us how many 8 ounce cups (approximately one 'sippy' cup) of each type of beverage your toddler currently drinks each day. Beverage
Write in the number of 8oz. cups drunk each day:
Water
Soda or pop
Pacifier Spoons and forks
22. Does your toddler currently take multivitamins? No; if no skip to question #24
Yes;
22a. Please specify the type of vitamin normally given: (Select one answer using an 'X') Multivitamins only Multivitamins plus iron
Juice
Multivitamins plus fluoride Multivitamins plus fluoride and iron
Milk
Other specific vitamin/mineral, please specify:
20. If your toddler drinks milk, which type(s)? (Mark all that apply using an 'X') Whole milk 2% milk
23. How many days per week on average does your toddler take multivitamins?
Skim milk Days per week Raw milk Soy milk Lactose-free milk Other (such as nut, rice, goat or hemp) Page 5 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
Questions 24 - 26 ask about your child's hair, eyes and skin
24. Which of the following best decribes your child's current hair color? (Select one answer using an 'X') Brown
Black
Blonde
Auburn
Red
25. Which of the following best decribes your child's skin tone? (Select one answer using an 'X') Very light/Likely to sunburn and has freckles Light/Usually sunburns with few, if any freckles Light/Intermediate or "average" Caucasian, as likely to sunburn as to tan Olive/Often tans Medium/Naturally brown skin Dark/Naturally black-brown skin
26. Which of the following best decribes your child's current eye color? (Select one answer using an 'X') Blue
Green
Grey
Dark Brown
Hazel or Amber
Red
Two different eye colors
Questions 27-39 ask about your child's habits and activities
27. Think about a typical weekday for your child in the last month. How much time would you say your child spends playing outdoors on a typical weekday?
Hours OR minutes 28. Think about a typical weekend day for your child in the last month. How much time would you say your child spends playing outdoors on a typical weekend day?
Hours OR minutes 29. On average, how many days per week has your child spent any time outside between the hours of 11am -3pm, since 24 months of age?
Days per week
30. When your child spends time outside during the summer months, which of the following types of skin protection are used (if any)? (Mark all that apply using an 'X') None
Long pants
Brimmed hat
Sunglasses
Long sleeves
Umbrella, tree or other shade producer
Sunscreen, if yes what SPF value is usually applied? SPF Value
Page 6 of 18
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program We would like to ask about some activities that your child may do Scribbling, drawing, painting, or playdough
Hours per day or 31. For the list of activities below, please check the appropriate box to indicate which activity or activities your child has participated in since he or she was 24 months old. For each activity that your child does or has done, please also tell us on average how many hours or minutes per day your child has usually spent doing the activity. (Mark all that apply using an "X")
or
or
Hours per day or
Minutes per day
Minutes per day
Hours per day or
Minutes per day
Hours per day or
Minutes per day
Hours per day or
Minutes per day
Running
or
Minutes per day Swimming
Listening to pre-recorded music
Hours per day
Minutes per day
Playing with other children who are older than your child
Playing computer games
Hours per day
Hours per day or
Minutes per day
Watching movies
Hours per day
Playing card games or board games such as matching, flash card or memory games
Playing with other children of the same age or younger
Watching television shows
Hours per day
Minutes per day
or
Minutes per day
Listening to others singing
Riding a tricycle *Check here if your child uses a helmet when riding
Hours per day
or
Minutes per day Hours per day or
Minutes per day
Singing (by him/herself or with others) Riding a bicycle
Hours per day
or
Minutes per day
*Check here if your child uses a helmet when riding
Dancing
Hours per day or Hours per day
or
Minutes per day
Listening to stories that an adult reads to your child
Hours per day
or
Minutes per day
or
32. Which of the following best describes your child's current play behavior: (Select one answer using an 'X') My child plays alone only My child plays with other children, but only boys
Listening to stories that are on tape or CD
Hours per day
Minutes per day
My child plays with other children, but only girls
Minutes per day
My child plays with other children, boys and girls
Page 7 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program 33. Has your child begun learning any of the following? (Mark all that apply using an 'X') Shapes and sizes Alphabet
Songs
Saying please and thank you
Colors
Nursery rhymes
Numbers 34. Which hand does your child usually use for the following activities? Eating
Left
Right
Either
Doesn't do this at all
Holding utensils
Left
Right
Either
Doesn't do this at all
Drawing
Left
Right
Either
Doesn't do this at all
Throwing a ball
Left
Right
Either
Doesn't do this at all
Coloring
Left
Right
Either
Doesn't do this at all
Holding a toothbrush
Left
Right
Either
Doesn't do this at all
35. Please tell us if your toddler does any of the activities listed below and, if so, under what circumstances. (Mark all that apply using an 'X')
Sucks on pacifier
Generally throughout the day
Generally throughout the day
While going to sleep
While going to sleep
During car rides
During car rides Thumb sucking
When finished eating
When finished eating
When feeling ill
When feeling ill
During tantrums
During tantrums
During teething
During teething Generally throughout the day
Generally throughout the day
While going to sleep
While going to sleep Sucks on other fingers
During car rides
Sucks on other objects such as blanket
When finished eating
During car rides When finished eating
When feeling ill
When feeling ill
During tantrums
During tantrums
During teething
During teething
36. My child shows an interest in potty training (Select one answer using an 'X'). No
Yes
Sometimes
37. Please tell us your child's current potty training status (Select one answer using an 'X'). My child is not at all potty trained;
if not at all, skip to #39
My child is partially potty trained My child is fully potty trained
Page 8 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program 38. Where does your child usually practice potty training? (Select one answer using an 'X') At childcare settings only
At home only
Both at home and when at childcare
39. How often in a normal week does your toddler usually have a bath or shower?
Times per week
Questions 40 - 49 ask about sleep habits 40. What is your child's current sleeping arrangement? (Select one answer using an 'X')
45. In the past year has your child regularly: (Mark all that apply using an 'X')
Infant crib in child's own room
Continued to get up after being put to bed
Infant crib in parents' room
Woken after only a few hours of sleep
Infant crib in room with a sibling
Had difficulty going to sleep
Toddler bed in child's own room
Refused to go to bed Woken very early
Toddler bed in parents' room Toddler bed in room with a sibling
Woken in the night Had nightmares
Other; please specify 46. Do you believe your child has a sleep problem? (Select one answer using an 'X') Yes, a very serious problem 41. Does your child have a regular sleeping routine? (Select one answer using an 'X')
Yes, a small problem No sleep problems at all
No
Yes
42. How much time does your child spend sleeping during the night (between 7 in the evening and 7 in the morning)?
47. Does your child usually sleep in a room with a humidifier on? (Select one answer using an 'X') No Yes, winter only
Hours Yes, year round 43. How much time does your child spend sleeping during the day (between 7 in the morning and 7 in the evening)?
48. Does your child usually sleep in the same bed with: (Mark all that apply using an 'X') Stuffed animals
Cat(s)
Dog(s)
Hours Other: 44. How many times does your child usually wake up during the night? 49. On average, how many times per month is your toddler's bedding washed and changed? Times per night Times per month
Page 9 of 18
29249
30 Month-Toddler Questionnaire Upstate KIDS: The Upstate New York Infant Development Screening Program
Questions 50-59 ask about childcare 50. Does your child attend daycare, or is s/he watched by a care provider, at least once per week? ( A care provider is someone other than the child's parents/guardians who watches the child.) No; if no skip to question #60
54. If you indicated above that your child is watched by a family member on a regular basis, which family member is the care provider used most often? (Do not include occasional sitting.) (Select one answer using an 'X')
Yes
51. If yes, what was your child's primary type of daycare since 24 months of age? (Select one answer using an 'X')
Toddler's Grandmother
Toddler's older sibling
Toddler's Grandfather
Toddler's cousin
Toddler's Aunt
Other; please specify:
A private home-based daycare Toddler's Uncle A group daycare facility My home with a nanny or sitter (not live-in)
55. On average, how many total hours per week does your child attend child care or get watched by a care provider?
My home with a nanny or sitter (live-in)
HOURS My home with a family member A family member's home
56. How old was your child (in months) when he/she began daycare or being watched by a care provider on a regular basis?
Other; please specify:
MONTHS 52. Are there other types of child care settings that you use at least once per week? No; if no skip to question #54
Yes
53. If yes, what are the other types of child care settings you use most often? (Mark all that apply using an 'X') A private home based daycare A group daycare facility My home with a nanny or sitter (not live in)
57. About how many children are usually cared for together, at the same time in the same group, at the daycare setting used most often for your child? If there is only one child cared for at the daycare setting, skip to question 59.
CHILDREN 58. What is the difference in age between the youngest and oldest child in the group your child is in at his/her day care setting? The ages of children in my child's group are: Within 1 year of my child
My home with a nanny or sitter (live-in) My home with a family member
Within 2 years of my child
A family member's home
Within 3 years of my child
Other, please specify:
Greater than 3 years different than my child's age 59. About how many adults usually care for your child at the same time at the daycare setting most often used?
ADULTS Page 10 of 18
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
Please tell us about your child's family environment 60. Please tell us if your child usually has an opportunity to spend time with any of the following people each month: (Mark all that apply using an 'X') Cousins Aunts and uncles Grandparents 61. Does your toddler currently live with other children who are under the age of 18? (Mark all that apply using an 'X') No Yes, my toddler lives with children younger than him/her Yes, my toddler lives with children older than him/her
The next two questions ask about your toddler's siblings. By "sibling" we mean your toddler's biological brother or sister as well as any step-siblings or adopted siblings your toddler may have. 62. Does your toddler have a sibling (brother or sister) enrolled in Early Intervention (EI) Services or Committee on Preschool Special Education (CPSE)?
No
Yes
If yes, please tell us how many of your toddler's siblings are enrolled in EI or CPSE and how old the siblings are currently. Number of siblings enrolled in EI, and their current age(s)
Number of siblings enrolled in CPSE, and their current age(s)
Age of Sibling 1 in EI
Age of Sibling 1 in CPSE
Age of Sibling 2 in EI
Age of Sibling 2 in CPSE
Age of Sibling 3 in EI
Age of Sibling 3 in CPSE
Age of Sibling 4 in EI
Age of Sibling 4 in CPSE
Age of Sibling 5 in EI
Age of Sibling 5 in CPSE
63. Does your toddler have a sibling (brother or sister) who has been diagnosed with any of the conditions listed below? (Mark all that apply using an 'X') Depression Anxiety Attention Deficit Hyperactivity Disorder (ADHD) Autism Autism Spectrum Disorder
Page 11 of 18
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
64. Has your child ever been enrolled in Early Intervention Services? (Select one answer using an 'X') No
Yes
65. Has your child received any of the developmental services listed below in the past 6 months? If so, please indicate which one(s) and when the services have been received. For each time period, please also indicate whether the service was received through the Early Intervention (EI) program or outside of Early Intervention. (Mark all that apply using an 'X')
Speech Services, such as Speech/Language Picture Exchange Communication System (PECS) Functional Communication Training (FCT) Sign Language Feeding Issues Occupational Therapy, such as Fine Motor Therapy Sensory Integration Services Physical Therapy
Adaptive or Assistive Technology
Special Education Services
Attends a Special Education Preschool
Psychology Services
Social Work Services
Behavioral Services
Play Therapy Residential Habilitation
Respite Services
Currently Receiving
Received in the past 6 months
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Received through EI
Received through EI
Received outside of EI
Received outside of EI
Autism-Related Services, such as Applied Behavioral Analysis (ABA) Discrete Trial Training
Other Please specify:
Page 12 of 18
30 Month-Toddler Questionnaire
29249
Upstate KIDS: The Upstate New York Infant Development Screening Program Questions 66-81 ask about your child's health status 66. If your child currently receives EI services, will s/he be transitioning to the Committee on Preschool Special Education (CPSE)? (Select one answer using an 'X') No
Yes
70. Has a medical professional ever recommended any of the following for your toddler? (Mark all that apply using an 'X') Ear tubes
Not Sure
Yes, and my child currently has Yes, but my child does not have
67. Does your toddler usually have difficulty passing stools? Eyeglasses No
No
Yes
No Yes, and my child currently has
68. On average, how often does your toddler have a bowel movement (or pass a stool)? (Select one answer using an 'X')
Yes, but my child does not have Hearing aid
No
More than once a day
Yes, and my child currently has
Everyday
Yes, but my child does not have
Every two days Every three to four days Every five to seven days Less than once a week 69. Is your toddler currently seeing a physician because of a specific medical concern? (Select one answer using an 'X') No; If no, skip to question #70 Yes
71. Has your child ever required medical attention for any of the following issues? (Mark all that apply using an 'X') Psychologically traumatic events (such as car accident) Swallowing anything dangerous (such as buttons) Put objects in nose or ears (such as button or eraser) Other major physical injuries (such as a concussion) Bites from an animal
69a. If yes, please mark an 'X' in each of the areas below for which your child is consulting a pediatrician: Vision
Hearing deficit
Anxiety
Developmental delay(s)
Underweight
Overweight
Bites from another child Scratches Broken bones Near drowning Poisoning
Physician-diagnosed asthma
Burns
Oppositional behavior or an extreme amount of defiance or consistently negative responses Height concerns; For height concerns mark an 'X' below: Short stature
Tall stature
For other medical problem; specify:
72. Has your toddler had his/her blood lead level tested? (Mark all that apply using an 'X') No Yes, when my toddler was 1 year old Yes, when my toddler was 2 years old
For other reason; specify:
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30 Month-Toddler Questionnaire
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Upstate KIDS: The Upstate New York Infant Development Screening Program
Please tell us about your toddler's dental health 73. Does your toddler go to the dentist? No
Yes;
If yes, at what age did your toddler first visit the dentist?
Questions 82 - 90 are updates since 24 months of age 82. Since your child was 24 months of age, has s/he been admitted to the hospital, even for a few hours? No
Yes
If yes, please indicate the number of times
Months of Age
and please specify the reason below:
74. Does your toddler ever have his/her teeth flossed? No
For illness; specify:
Yes
75. Does your toddler ever have his/her teeth brushed? No; if no skip to #80
For surgery that required admission for more than 1 day, specify:
Yes
76. Does anyone assist your toddler in teeth brushing? No
Yes
For day surgery (outpatient) specify:
77. Does anyone supervise your toddler's teeth brushing? No
Yes
78. Does your toddler use fluoride-free toothpaste? No
Yes
83. Since your child was 24 months of age, has s/he had an ear infection diagnosed by a doctor? No
Yes; If yes, how many?
79. At what age did your toddler start brushing his/her teeth? 84. Since your child was 24 months of age, has s/he had an infection for which an antibiotic was prescribed? Months of Age 80. How many cavities has your toddler had in his/her life?
Cavities; if none, skip to #82 81. If your toddler has had any cavities corrected with fillings, how many fillings of each type has your toddler had? a. Cavities filled with plastic (or composite resin)
b. Cavities filled with silver or amalgam
No
Yes;
If yes, how many?
85. Since your child was 24 months of age, has your child had any wheezing attacks? (By wheezing, we mean breathing that sounds like a high-pitched whistling or a squeaking sound coming from the toddler's chest not throat)?
No
Yes;
If yes, how many wheezing attacks has your child experienced since age 24 months?
c. Cavities with an unknown type of filling Wheezing attacks d. Cavities filled with another type of filling (such as gold, porcelain, or glass ionomer) Page 14 of 18
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
86. If your child has had antibiotics prescribed for infections since 24 months of age, which types of treatments were used to treat those infections and how many times was each treatment type used? (Mark all that apply using an 'X') Oral antibiotics
# of times
Ear drops with antibiotics
# of times
Pain killers (e.g., Tylenol)
# of times
88a. If yes, what type of medical device or monitor does your child use? (Mark all that apply using an 'X') Catheter
Ventilator
Dialysis equipment
Cardiac monitor
Nebulizer Apnea or respiratory (breathing) monitor Combined heart rate and respiratory monitor
Decongestant s
# of times
Ear drops for wax
# of times
Other, specify:
# of times
Other:
89. Since age 24 months, has your toddler ever had frequent sneezing and/or prolonged blocked or runny nose for several months when he/she did not have a cold or the flu? No
87. Since age 24 months, have you been told by a doctor or health practitioner that your toddler is allergic to any food, medication or other things? No
FOOD
Yes; If yes, what are the specific allergies? (Mark all that apply using an 'X')
Nuts
Wheat
Peanuts
Eggs
Dairy
Shellfish
Fish
Gluten
Cows milk
Soy
Yes
90. Since age 24 months, did a doctor or health care practitioner ever tell you that your toddler had eczema or atopic dermatitis (dry, itchy inflammation of the skin, redness and swelling)? No
Yes; If yes, below please specify location(s) on the body: (Mark all that apply using an 'X')
Legs
Scalp
Face
Chest
Buttocks
Arms
Abdomen
Back
Palms of hands
Soles of feet
Other; specify: Type of medication:
Vaccinations MEDICATION
Type of medication: 91. Has your child ever been vaccinated? No
Type of medication:
Yes; if yes skip to #93
OTHER
Pollen
Animals
Dust
Ragweed
Don't know
88. Since age 24 months, has your child used a medical device in the home? No; if no skip to #89
Yes
92. If your child has never been vaccinated, please indicate why, and then skip to #95. (Mark all that apply using an 'X') Religious reasons
Medical reasons
Personal reasons
93. When your child is vaccinated, is s/he usually given Tylenol® or Motrin®? No
Yes Page 15 of 18
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
94. Please use your Child Health Journal (pages 2-7), to answer the following question about any vaccinations your toddler has recently received, if you have not previously reported them to us. If you cannot remember or did not record vaccination dates, please provide as much of the date as you can remember. If your toddler received a combined vaccine, such as Pediarix ® or Comvax®, you do not also have to mark that the individual vaccines were received.
Vaccine
Dose
Varicella (Chickenpox) Hepatitis A
Recommended Age Range
1
12-15 months
2
18-24 months
Received
mm
/
Date of Vaccine dd /
/ /
/ /
Meningococcal
As needed
/
/
Seasonal influenza (not H1N1)
As needed
/
/
Tetanus (Tdap)
As needed
/
/
Other combined vaccine Please specify the combined vaccine name:
/
/
Second other combined vaccine
/
/
Please specify the second combined vaccine name:
yyyy
95. Please fill in the chart below about your toddler's growth and well-child check-ups since your child was 24 months of age. For each visit, please include your toddler's age (in months) and the actual date of the check-up. If you cannot remember the complete date, please provide as much of the date as you can remember. Feel free to consult your child health journal (pages 14-28) to answer this question. Age at Visit (months)
Date of Visit (mm/dd/yyyy)
Length (inches or centimeters)
Weight (pounds or kilos)
Head Circumference (inches or centimeters) lbs
/
/
Date of Visit (mm/dd/yyyy)
in
or
. .
Months
Age at Visit (months)
..
cm
Length (inches or centimeters)
.
.
or
or
.
kilos
Weight (pounds or kilos)
.
in
cm
Head Circumference (inches or centimeters) lbs
/ Months
/
..
in
or
. .
cm
.
.
or
or
.
kilos
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in
cm
30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
96. Please complete the chart below about which teeth your toddler has.* The figure below illustrates the location of various types of teeth and is identical to page 10 of your child health journal. Feel free to review the journal in completing this chart.
*Any tooth eruption dates that you reported on your previous Upstate KIDS questionnaire(s) do not need to be reported to us again. Upstate KIDS will not be asking about tooth eruption in future questionnaires!
teeth eruption dates American Dental Association Primary Teeth Eruption Chart
Upper teeth eruption dates
Lower teeth eruption dates
Please record the date that you first noticed the tooth
Please record the date that you first noticed the tooth
Right Central Incisor
/
/
Right Central Incisor
/
/
Left Central Incisor
/
/
Left Central Incisor
/
/
Right Lateral Incisor
/
/
Right Lateral Incisor
/
/
Left Lateral Incisor
/
/
Left Lateral Incisor
/
/
Right Canine (Cuspid)
/
/
Right Canine (Cuspid)
/
/
Left Canine (Cuspid)
/
/
Left Canine (Cuspid)
/
/
Right First Molar
/
/
Right First Molar
/
/
Left First Molar
/
/
Left First Molar
/
/
Right Second Molar
/
/
Right Second Molar
/
/
Left Second Molar
/
/
Left Second Molar
/
/
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30 Month-Toddler Questionnaire 29249
Upstate KIDS: The Upstate New York Infant Development Screening Program
SICK VISITS 97. Please fill in the chart below about your child's sick visits since he or she was 24 months of age. For each visit, please include the actual date of the check-up, the health concern, and the treatment. If you cannot remember the complete date, please provide as much of the date as you can remember. This information is in the Sick Visits section of your child health journal (p. 29-31).
Please enter the number of your response(s); if other, please specify. Date of Visit - mm/dd/yyyy
Treatment:
Health Concern:
1-Ear Infection
4-Diarrhea
2-Cold
5-Rash
1-Antibiotic 4-Topical Drops 2-Tylenol 5-Ointment
3-Vomiting
6-Pink Eye
3-Pedialyte
6-Other
7-Other Date of Visit - mm/dd/yyyy
/
Health Concern:
Treatment:
Health Concern:
Treatment:
Health Concern:
Treatment:
/
Date of Visit - mm/dd/yyyy
/
Treatment:
/
Date of Visit - mm/dd/yyyy
/
Health Concern:
/
Date of Visit - mm/dd/yyyy
/
Treatment:
/
Date of Visit - mm/dd/yyyy
/
Health Concern:
/
98. If you have a computer and internet access, would you be interested in completing future Upstate KIDS questionnaires online? Yes No I do not have computer/internet access
THANK YOU FOR YOUR PARTICIPATION IN
Scan Date
Please mail this form out to us soon! If you misplaced the postage-paid envelope that was mailed with this questionnaire, please call us and we will mail you another return envelope. 1-888-870-0247 (Toll-free) Upstate KIDS Program Office University at Albany School of Public Health 1 University Place, Room 216 Rensselaer, NY 12144
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