Questionnarie of child's development and health(to be completed by a parent or a guardian)(for office use only)※ Please circle the applicable answers, and fill in ( all the required fields ) without omissions, if applicable. If you are
expecting a baby, please fill in your familiy name and due date in the space of Child's Name and Date of Birth.

Date of BirthChild's Name

Male・Female

the 1st choiceyear

Heisei ・Reiwa

month/

入所希望day

月( Age as of April 1, 2024 ）/year(s)month(s)the 6th choice※Getting to know your child better, the Department of Child & Family Services

the 2nd choice

the 7th choice

the 3rd choice

the 8th choiceYour Choice the 4th choice

the 9th choice

the 5th choice

the 10th choice

may contact a guardian later. Please fill in the name and contact number of theguardian who knows your child well.

the Nursery
School ofGuardian's nameTel.

Question1
BirthConditions

Did your child have any health problems during the period

Yes（from pregnancy to childbirth?

）・ No

2

Condition of Birth

Normal・Others

3

Birth Weight（45Did your child have any problems at birth / in the neonatal
period?
holds up his/her head（months）

rolls over（creeps on hands and knees（months）

walks holding onto funiture（months）

Cesarean Section・Vacuum Extraction・Birth Asphyxia
in case of premature birth ;)ｇ

A baby was born at（）・ Nomonths）

sits up on his/her own（walks without support（Yes ・No

7

Does your child look back when his/her name is called from behind?

Yes ・No

8

Does your child point to an object or a picture when it's named?

11

Yes（as "Mama(mother)" or "Vroom-Vroom(car)"?
Does your child say two-word sentences/phrases (ex.
"Doggie coming.", "More num-num") ?
Does your child use simple phrases or micro sentences tocommunicate with others?
Yes・No

13 Does your child change clothes by himself/herself ?
14 Does your child use a toilet ?
15months）・

Does your child say several meaningful single words, such

12 Does your child eat by himself/herself ?

Has your child ever had a Health Check for infants andchildren?

Yes ・NoYes ・NoYes ・Nohands

Yes ・Yes・No

months）months）

Does your child look into your eyes when you talk to him/her?

10）weeks.

Yes（69DevelopmentAnswer・spoon

does with help

No・ chopsticks・No

diapers ・ duaring potty training ・ underwear

one-and-a-half-year-old ・ three-year-old ・ No
□ goes to a Medical Institution regularly

Have you ever been told that your child may have a mental

16three-year-old) ?

）Disease Name（）□ My child is told that "Folow-up" is needed at a healthand physical delay or language delay at his/her Health
Check for infants and children (one-and-a-half-year-old ・Name of the Medical Institution（center.

Yes ・ No□ My child has participated in a parent-child class at "AnStep" that is a support center for child's development.
□ I consult staff of "An Step" about my child.

※If you answered "Yes", please check the box next to your□ goes to a developmental support class（Yamabiko Room)answer.

that is in "An Step" for children from around 1year old topreschool.
□Others（HealthCondition

17

Have you ever been told that your child may have a vision
problem or a hearing problem?

Yes ・ No）

Disease Name (Family Doctor（

Please fill in other side also.

））

18 Does your child have a physical disability?

Yes ・ No

Disease Name（）

Family Doctor（）

Age at the time of the first convulsions
year(s)19

Has your child ever had any convulsions, seizures or
epilepsy?

month(s)Age at the time of the last convulsions

Yes ・ No

year(s)months(s)How many times has it happened so far ?

time(s)when ( had a high fever・cried hysterically ）Disease Name（）

Allergy Test（ done ・ not yet ）Allergen（20Does your child have any allergies?
If you ansewed "Yes", please fill in your child situatoion.

Yes ・ No）

Symptom（diarrhea ・ eczema ・ vomit ・ others）
Anaphylactic Shock ( Yes ・ No
Carries an EpiPen（ Yes ・ No））

Family Doctor（Disease Name）

21

Does your child have a chronic illness?

Yes ・ No( ex. heart disease・asthma ）（）Family Doctor（）

things that need consideration（HealthCondition）

Disease Name（
22

Has your child ever had a serious illness before?
(illness that need consideratin in the school life of nursery）

Yes ・ No）

Family Doctor（）

things that need consideration（）□ doesn't understand the words, and doesn't talk□ understands the words, but does't talk□ says several single words

Do you think your child may have a language delay?
23 ※ If you answed "Yes" or " a little worried", please checkthe box next to your answer.

Yes ・ No ・a little worried□ says two-word sentences/phrases(ex. Mama juice）□ says three-word sentences/phrases(ex. Mama more juice)□ repeats words headover□ stuttering

24 Do you think your child may have a mental delay?

Yes ・ No ・ Disease Name（

Does your child have a physically disabled pocketbook, a
25 disabled person's pocketbook or an intellectual disabled）

a little worried Family Doctor（Yes・No）

physically disabled pocketbook （Grade）

disabled person's pocketbook （Grade）

intellectual disabled pocketbook（pocketbook?
Family Doctor（Question)Decision）

Answer※ If you have any concerns about your child, please write them below.
(ex. Child's Development : phycial/mental /language,(For office use only)

Things you want us to be careful at a nursery school)

子ども確認不可証明担当者印