Fill and Sign the Minnesota Questions Child Form

SAMPLE QUESTIONS TO ASSIST IN DETERMINATION OF PRIMARY CARETAKER Infants 1. How many times a day does the baby need to have her/his diapers changed? 2. When was the last time you changed the baby's diaper? 3. In a typical day, do you change the baby's diaper more than once? 4. Do you change any of her/his diapers? 5. How many times a week do the baby's clothes get washed? 6. How many times a week do you wash the baby's clothes. 7. When was the last time you washed the baby's clothes? 8. What detergent did you use? 9. How much does it cost to wash and dry the baby's clothes each week? 10. When was the last time you put the baby's clothes away? 11. How many times a day does the baby get her/his clothes changed? 12. How many times a day do you dress the baby? 13. When was the last time you dressed the baby? 14. When was the last time you ironed the baby's clothes? 15. How often does the baby need new clothes? 16. How often do you shop for and buy the baby new clothes? 17. When was the last time you shopped for and bought the baby new clothes? 18. What did you buy? What size? 19. How many times a month do new supplies need to be bought for the baby; e.g., baby powder, baby shampoo, diapers? 20. How many times a month do you buy supplies for the baby? 21. When was the last time you bought baby supplies? - 1 - 22. How many times a day does the baby get fed/get a bottle? 23. How many times a day do you feed the baby? 24. When was the last time you fed the baby? 25. How many times a day do you prepare the baby's food or bottle? 26. When was the last time you prepared the baby's food or bottle? 27. How many times a week do you need to shop for more baby food? 28. When was the last time you shopped for the baby's food? 29. What was the first solid food your baby ate? 30. What foods does your baby eat now? 31. What foods does your baby refuse to eat? 32. How many times a week does the baby get a bath? 33. How many times a week do you give the baby a bath? 34. When was the last time you gave the baby a bath? 35. How many times a week does the baby get taken outside for a ride in the stroller or carriage or to the park? 36. How many times a week do you take the baby out in the stroller or carriage or to the park? 37. How often does a babysitter take care of the baby? 38. How many times a month do you arrange for the babysitter? 39. When was the last time you called the babysitter? 40. What arrangements do you usually make with the babysitter? 41. What is the babysitter's name? 42. When was the last time you dropped the baby off at the babysitters? 43. When was the last time you picked the baby up from the babysitters? 44. Where does the babysitter live? - 2 - 45. Does the baby have a routine childcare or daycare? 46. What are the hours that the baby is in daycare? 47. How many times a week does the baby go to daycare? 48. How many times a week do you pick the baby up from daycare? 49. What is the name of the daycare center? 50. What is the address of the daycare center/or where is the daycare center located? 51. What are the names of the daycare teachers? Name of the Director? Names of other parents and children? 52. How did you find out about the daycare center? 53. How many times a week does the baby wake up in the middle of the night? 54. When was the last time you tended to the baby in the middle of the night? 55. How many times a month or year does the baby get taken to the doctor for a routine checkup? 56. When was the last time you took the baby on a routine checkup to the doctor? 57. How many times in the last six months or year has the baby been sick? 58. What was the last sickness your child had? 59. How many times in the last six months or year have you taken off work to take care of the baby while she/he was sick? 60. When was the last time you took off work to take care of the baby when she/he was sick? 61. How many times in the past six months or year has the doctor been called because of the baby's illness? 62. How many times in the past six months or year have you called the doctor because the baby was ill? 63. When was the last time you called the doctor because the baby was ill? 64. What is the name of the baby's doctor? 65. What is the doctor's address? How far from your home is the doctor? 66. Who chose the baby's doctor? How was the choice made? - 3 - 67. What allergies, if any, does the baby have? 68. How often do you take pictures of the baby? 69. When was the last time you took pictures of the baby? 70. When was the last time you got up in the middle of the night to close the window in the baby's bedroom? 71. What are the baby's favorite toys? 72. What is the baby's favorite food? 73. How many teeth does the baby have? 74. How much does the baby weight? 75. How long is the baby? 76. How often do you cut the baby's fingernails? Toenails? Hair? 77. When was the last time you cut the baby's fingernails? Toenails? Hair? 78. What words does your child say? 79. How often does the baby visit members of his/her extended family? 80. Who arranges these visits? 81. Who takes the baby on these visits? 82.Who are the family members who are visited? - 4 - SAMPLE QUESTIONS TO ASSIST IN DETERMINATION OF PRIMARY CARETAKER Toddler/Preschool 1. How old was your child when she/he became toilet trained? 2. Who toilet trained your child? How? 3. How long did it take for your child to become toilet trained? 4. How many times a week does your child have a bath? 5. How many times a week do you bathe your child or prepare your child's bath? 6. When was the last time you bathed your child or prepared her/his bath? 7. How many times a week do you dress your child in the morning? 8. When was the last time you dressed your child in the morning? 9. How many times a week do you dress your child for bed? 10. When was the last time you dressed your child for bed? 11. To what extent does your child dress him/herself? 12. How many times a year does your child need new clothes? 13. How many times a year do you shop for new clothes? 14. When was the last time you shopped for clothes? 15. What size clothing does your child wear? 16. How many times a year does your child need new shoes? 17. How many times a year do you take your child to buy new shoes? 18. When was the last time you took your child to buy new shoes? 19. What size shoes does your child wear? 20. How many times a week do your child's clothes need to be washed? 21. How many times a week do you wash your child's clothes? 22. When was the last time you washed your child's clothes? - 5 - 23. How many times a week do you put your child's clothes away after they have been washed? 24. When was the last time you put your child's clothes away? 25. How many times a day do you clean up after your child; e.g., remove her/his toys from the living room? 26. When was the last time you cleaned up after your child? 27. How many times a month does your child need new supplies? 28. How many times a month do you buy new supplies for your child? 29. When was the last time your bought new supplies for your child? 30. How many times a day do you prepare your child's meals? 31. When was the last time you prepared your child's meal? 32. How many times a week do you take your child on children's activities; e.g., the park, the zoo? 33. When was the last time you took your child to an activity? 34. How many times a week does a babysitter take care of your child? 35. How many times a week do you arrange for a babysitter? 36. What is the babysitter's name? 37. When was the last time you called the babysitter? 38. How many times a week does your child go to daycare or nursery school? 39. Did you take your child to daycare or nursery school on her/his first day? 40. How many times a week do you take your child to daycare or nursery school? 41. How many times a week do you pick your child up from daycare or nursery school? 42. When was the last time your took your child to daycare or nursery school? 43. When was the last time you picked your child up from daycare or nursery school? 44. What is the name of the daycare center or nursery school which your child attends? 45. Where is the daycare center or nursery school located? Address? - 6 - 46. What are the names of the teachers who supervise your child at the daycare center? 47. What kinds of activities does the daycare center or nursery school have for your child? 48. When was the last time you attended a parent/teacher conference? 29. How many times a week do you talk to your child about her/his daily activities? 50. How many times in the past year or past six months have you left work to pick up your child from daycare or nursery school because she/he was sick? 51. How many times a month does your child wake up in the middle of the night? 52. How many times a month do you tend to your child when she/he wakes up in the middle of the night? 53. How many times a week do you play with your child? 54. How many times a week do you read to your child? 55. How many times a week do you teach your child basic information; e.g., teach her/him the alphabet, counting? 56. What is your child's favorite toy? 57. What is your child's favorite book? 58. Who is your child's best friend? 59. How many times a year does your child go to the doctor on a routine visit? 60. How many times a year have you taken your child to the doctor for a routine visit? 61. How many times has your child been taken to the doctor due to an illness? 62. How many times a year have you taken your child to the doctor due to her/his illness? 63. How many times a year have you called the doctor when your child was ill? 64. What was/were the illness(es)? 65. What is the name of your child's doctor? 66. What is the address of your child's doctor? 67. How did you choose this doctor? - 7 - 68. When was the last time you took your child to the doctor for a routine visit? 69. When was the last time you took your child to the doctor due to an illness? Was any medication prescribed? What? 70. How many times a year does your child have routine dental checkups? 71. How many times a year have you taken your child on a routine dental checkup? 72. When was the last time you took your child on a routine dental checkup? 73. What is the name of your child's dentist? 74. Where is the dentist located? 75. How did you choose this dentist? 76. When was the last time you took pictures of your child? 77. What time does your child go to bed at night? 78. How many times a week do you put your child to bed at night? 79. When was the last time you put your child to bed at night? 80. What time does your child wake up in the morning? 81. How many times a week do you wake your child up in the morning? 82. When was the last time you woke your child up in the morning? 83. What time in the afternoon does your child take a nap? 84. How many times a week do you put your child down for a nap? 85. When was the last time you put your child down for a nap? 86. What, if any, allergies does your child have? 87. Which, if any, childhood diseases has your child had; e.g., measles, chicken pox? 88. Does your child have an imaginary friend? 89. What is the friend's name? 90. What does your child do with the friend? 91. When was the last time you cut your child's fingernails? toenails? Hair? - 8 - 92. How often does the child visit members of his/her extended family? 93. Who arranges these visits? 94. Who takes the child on these visits? 95. Who are the family members who are visited? 96. What behavior of your child requires discipline? 97. What discipline is used? 98. How was it determined what discipline would be used? 99. Who administers the discipline? 100. How often is your child disciplined? - 9 - SAMPLE QUESTIONS TO ASSIST IN DETERMINATION OF PRIMARY CARETAKER Elementary School/Ages 5 through 12 1. Did you take your child to school on her/his first day? 2. What is the name of your child's school? 3. Where is the school located? 4. Did you pick your child up from school on her/his first day? 5. How many times a week do you walk or drive your child to school or bus stop? 6. How many times a week do you pick your child up from school? 7. When was the last time you walked or drove your child to school or bus stop? 8. How many times a week do you take care of your child after school? 9. When was the last time you took care of your child after school? 10. What outside activities is your child involved in; e.g., BoyScouts, GirlScouts, softball, etc.? 11. What is the name of each person who supervises each of these activities? 12. How many times a week do you take your child to her/his outside activities? 13. When was the last time you took your child to her/his outside activities? 14. When was the last time you picked your child up from her/his outside activities? 15. Who does your child call on the telephone when she/he returns from school? 16. Has your child ever had to leave school due to an illness? Who did the school call to inform of the illness? 17. How many times a year have you left work to pick your child up from school because she/he was ill? 18. When was the last time you picked your child up from school because she/he was ill? 19. How many times a year have you stayed home from work to care for your child when she/he was ill? 20. When was the last time you stayed home from work to care for your child when she/he was - 10 - ill? 21. How many times a year does your child go to the doctor for a routine visit? 22. How many times a year have you taken your child to the doctor for routine visits? 23. When was the last time you took your child to the doctor for a routine visit? 24. How many times in the last six months has your child been ill? 25. What illnesses has your child had in the last six months? 26. How many times in the last year have you called the doctor because your child was ill? 27. What is your child's doctor's name? 28. Where is your child's doctor located? 29. How did you choose your child's doctor? 30. When was the last time you took your child to the doctor because she/he was ill? 31. How many times a year does your child have routine dental checkups? 32. How many times a year have you taken your child on a routine dental checkup? 33. What is the name of your child's dentist? 34. Where is the dentist located? 35. How did you choose this dentist? 36. How many times a week do you wake your child up for school? 37. When was the last time you woke your child up for school? 38. How many times a week do you tuck your child into bed at night? 39. When was the last time you tucked your child in bed at night? 40. How many times a day do you prepare your child's meals? 41. When was the last time you prepared your child's meal? 42. What foods does your child like? 43. What foods does your child refuse to eat? - 11 - 44. How many times a week do you help your child with her/his homework? 45. What is the name of your child's teacher? 46. What was the name of your child's teacher in each grade? 47. Who is the principal of your child's school? 48. How many times a year are parent/teacher conferences held at your child's school? 49. How many times a year have you attended parent/teacher conferences? 50. When was the last time you went to a parent/teacher conference? 51. What are the grades that your child receives in her/his subjects; e.g., math grade, English grade? 52. What area has your child been particularly interested in and excelled at? 53. What, if any, awards has your child won? 54. What area has caused difficulty for your child? 55. How many times a year do you buy school supplies for your child? 56. When was the last time your bought school supplies for your child? 57. What is your child's favorite sports activity? 58. What is one of your child's favorite books? 59. How many times a month do you take your child to the public library? 60. When was the last time you took your child to the public library? 61. When was the last time you read to your child? 62. How many times a month does a babysitter watch your child? 63. How many times a month do you arrange to have a babysitter take care of your child? 64. When was the last time you arranged to have a babysitter take care of your child? 65. How many times a week does your child attend an after school daycare program? 66. Does your child attend any religious school? If so, what is the name of the religious school? Who selected the religious school? - 12 - 67. How many times a week does your child attend religious school? 68. How many times a week do you pick your child up from her/his religious school? 69. When was the last time you picked your child up from her/his religious school? 70. How often does your child attend religious services? 71. How often do you take your child to religious services? 72. When was the last time you took your child to a religious service? 73. What, if any, allergies does your child have? 74. What is the treatment for these allergies? What medication does s/he take? How often is it administered? 75. How many times a week does your child bathe? 76. How many times a week do you help your child with her/his bath? 77. How often does your child wash his/her hair? 78. Who reminds your child to bathe and wash his/her hair? 79. When was the last time you reminded your child to bathe and wash his/her hair? 80. How many times a week does your child's laundry need to be cleaned? 81. How many times a week do you clean your child's clothes? 82. When was the last time you did your child's laundry? 83. How many times a year does your child need to go shopping for new clothes? 84. How many times a year do you take your child shopping for new clothes? 85. How many times a year does your child need new shoes? 86. How many times a year do you take your child to buy new shoes? 87. When was the last time you took your child shopping for new clothes? 88. When was the last time you took your child shopping for new shoes? 89. What size clothes does your child wear? 90. What size shoes does your child wear? - 13 - 91. When was the last time you planned a birthday party for your child? 92. When was the last time you supervised visits with friends? 93. Who is your child's best friend? 94. Where does s/he live? 95. How many hours a week does your child watch television? 96. What are his/her favorite television programs? 97. Are there any restrictions on your child's television watching? What are they? 98. How often does the child visit members of his/her extended family? 99. Who arranges these visits? 100. Who takes the child on these visits? 101. Who are the family members who are visited? 102. What behavior of your child requires discipline? 103. What discipline is used? 104. How was it determined what discipline would be used? 105. Who administers the discipline? 106. How often is your child disciplined? - 14 - SAMPLE QUESTIONS TO ASSIST IN DETERMINATION OF PRIMARY CARETAKER Adolescents: Ages 13 through 17 1. How many times a day do you prepare your child's meals? 2. When was the last time you prepared your child's meals? 3. What foods does your child like and dislike? 4. How many times a year does your child need new clothes? 5. How many times a year do you go shopping with your child to buy her/him new clothes? 6. When was the last time you went shopping with your child to buy her/him new clothes? 7. How many times a year does your child need new shoes? 8. How many times a year do you go shopping with your child to buy her/him new shoes? 9. What size shoes does your child wear? 10. When was the last time you went shopping with your child to buy her/him new shoes? 11. What is the name of your child's school? 12. Where is the school located? 13. How many times a week do you drive your child to school or walk to the bus? 14. How many times a week do you pick your child up from school? 15. When was the last time you drove/walked your child to school or bus? 16. When was the last time you picked your child up from school? 17. What outside activities is your child involved in; e.g., sports teams, drama club, music groups? 18. What is the name of the supervisor of each of these activities? 19. When was the last time you watched your child at a performance? 20. How many times a week do you take your child to her/his outside activity? 21. How many times a week do you pick your child up from her/his outside activity or to visit a - 15 - friend? 22. When was the last time you attended any of your child's outside activities? 23. When was the last time you took your child to her/his outside activity? 24. When was the last time you picked your child up from her/his outside activity? 25. How many times a year does your child go to the doctor for a routine checkup? 26. How many times a year have you taken your child to the doctor for a routine checkup? 27. When was the last time you took your child to the doctor for a routine checkup? 28. What illnesses and/or injuries has your child had in the past year? 29. Has your child had chicken pox? 30. How many times in the last year did you call the doctor because of your child's illness or injury? 31. How many times in the last year did you take your child to the doctor or hospital because she/he had an illness or injury? 32. When was the last time you took your child to the doctor because she/he had an illness or injury? 33. When did your child last miss school due to illness? 34. Who stayed home with him/her? 35. When was the last time you took your child to the eye doctor? 36. What is the name of your child's doctor? 37. Where is the doctor located? 38. How did you choose this doctor? 39. How many times a year does your child have routine dental checkups? 40. How many times a year do you take your child for her/his routine dental checkup? 41. When was the last time you took your child for her/his routine dental checkup? 42. What is your child's dentist's name? 43. Where is this dentist located? - 16 - 44. How did you choose this dentist? 45. How many times a week do you wake your child up for school? 46. When was the last time you woke your child up for school? 47. How many times a week do you help your child with her/his homework? 48. When was the last time you helped your child with her/his homework? 49. What subject does your child most need help in? 50. What is the name of your child's teacher? (If the child has more than one teacher, what are their names?) 51. Who is your child's favorite teacher? 52. Are there any teachers your child does not like? Why? 53. What is the name of the principal at your child's school? 54. How many times a year are parent/teacher conferences held at your child's school? 55. How many times a year have you attended parent/teacher conferences held at your child's school? 56. When was the last time you attended a parent/teacher conference held at your child's school? 57. What subjects does your child take in school? 58. What are the grades your child receives in her/his subjects? 59. Who writes notes to the school when your child needs to be excused? 60. What area(s) has your child been particularly interested in and excelled at? 61. What, if any, awards has your child won? 62. What area has caused difficulty for your child? 63. How many times a year do you buy school supplies for your child? 64. When was the last time you bought school supplies for your child? 65. What is your child's favorite sports activity? - 17 - 66. What hobbies does your child have? 67. Do you participate in any of your child's hobbies? 68. Does your child attend any religious school? 69. If so, what is the name of the religious school? 70. Where is it located? 71. How many times a week does your child attend religious school? 72. How many times a week do you take your child to religious school? 73. When was the last time you took your child to religious school? 74. When was the last time you picked your child up from religious school? 75. How often does your child attend religious services? 76. How often do you take your child to religious services? 77. When was the last time you took your child to religious services? 78. What, if any, allergies does your child have? 79. How many times a week does your child's laundry need to be cleaned? 80. How many times a week do you clean your child's laundry? 81. When was the last time you cleaned your child's laundry? 82. Which, if any, of your child's graduation ceremonies have you attended? 83. Where was the ceremony held? 84. How many times a week, if any, have you given your child driving lessons? 85. When was the last time you gave your child a driving lesson? 86. Who is your child's best friend? 87. How often do they see each other? 88. Where do they get together? 89. Does your child go to summer camp? If so, where? - 18 - 90. What does your child do in summer camp? 91. How did your choose the camp? 92. What was the name of your child's counselors? 93. Does your child go to summer school? 94. What magazines does your child read? 95. What was the last book your child read? 96. How many hours a week does your child watch television? 97. What is her/his favorite television program? 98. Are there any restrictions on your child's television watching? What are they? 99. How often does the child visit members of his/her extended family? 100. Who arranges these visits? 101. Who takes the child on these visits? 102. Who are the family members who are visited? 103. When was the last time you took your child for a haircut or cut her/his hair? 104. How often does your child bathe? 105. How often does your child wash his/her hair? 106. Who reminds your child to bathe and wash his/her hair? 107. When was the last time you reminded your child to bathe and wash his/her hair? 108. Does your daughter menstruate? If so, when did she begin to menstruate? 109. How did your daughter learn about menstruation? 110. With whom does your child discuss the bodily changes which accompany puberty? 111. Has s/he ever discussed these changes with you? 112. When was the last time s/he discussed these changes with you? 113. What are his/her concerns about these changes? - 19 - 114. Has your child read any books concerning puberty or sex education? If so, what are they? 115. Who selected these books? 116. Have you read these books yourself? - 20 -