Infant Characteristics Questionnaire
Help us understand your infant’s temperament and behaviors by answering the following questions.
Your Name
*
First Name
Last Name
Relationship to Infant
*
Mother
Father
Primary Caregiver
Other
Infant's Full Name
*
First Name
Last Name
Infant's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infant's Gender
*
Male
Female
Other
Please rate the following statements about your infant's behavior.
*
Rows
Never
Rarely
Sometimes
Often
Always
Is active and moves around a lot
1
2
3
4
5
Adapts easily to new situations
6
7
8
9
10
Cries intensely when upset
11
12
13
14
15
Smiles or laughs easily
16
17
18
19
20
Has regular sleeping patterns
21
22
23
24
25
Is easily distracted
26
27
28
29
30
Shows strong reactions to new foods
31
32
33
34
35
Is generally in a good mood
36
37
38
39
40
How easily does your infant calm down after being upset?
*
Very easily
Somewhat easily
With some difficulty
With great difficulty
How does your infant typically react to new people?
*
Very friendly
Cautious but warms up
Shy or withdrawn
Please rate your infant’s overall temperament.
*
1
2
3
4
5
Is there anything else you would like to share about your infant’s characteristics or behavior?
Submit Questionnaire
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