About Your Child
1. What FOODS does your child especially like? _____________________________________________________________________________
2. Especially DISLIKE? _____________________________________________________________________________
3. Favorite toys, games, activities?
_____________________________________________________________________________
4. Is your child TOILET TRAINED? ______ What words does your child use for toilet?
________________
5. How does your child express ANGER or frustration?
_____________________________________________________________________________
6. Does your child have any special FEARS?
_____________________________________________________________________________
Explain _____________________________________________________________________________
7. When your child is upset, what helps to COMFORT him/her?
_____________________________________________________________________________
8. How do you DISCIPLINE your child?
_____________________________________________________________________________
9. Has your child been taking an afternoon NAP? ___________ If so, how long?_______________
If not, why? _____________________________________________________________________________
10 . Special toy or blanket for NAP?
_____________________________________________________________________________
11. Special FAMILY situations? ( such as custody specifications, problems arising from
situations, etc.)__________________________________________________________________________
_____________________________________________________________________________
12. Anticipated ADJUSTMENT problems?
_____________________________________________________________________________
_____________________________________________________________________________
13. Any disorders/developmental (slow, advanced) diagnosed or suspected?
_____________________________________________________________________________
14. Previous childcare child has attended:
_____________________________________________________________________________
15. Any problems at previous daycares?
_____________________________________________________________________________
16. EXPECTATIONS of Day Care Home _____________________________________________________________________________
_____________________________________________________________________________
17. Other COMMENTS? _____________________________________________________________________________
_____________________________________________________________________________
Health History
1. Child’s name ____________________________________BirthDate _____________________
2. Last Physical Examination _______________________________________________________
3. Illnesses: (please circle)
Does your child have any problems with any of these?
Has your child had any of these diseases?
Constipation Asthma
Convulsions Bronchitis
Diarrhea Chicken Pox
Fainting Spells Diabetes
Frequent Colds Heart Disease
Frequent Ear Infections Hepatitis
Frequent Sore Throats Impetigo
Lice Measles
Ringworm Mumps
Skin Rash German Measles
Soiling Polio
Stomach Upsets Scarlet Fever
Urinary Problem Tuberculosis
Worms Whooping Cough
3. Other ILLNESSES? (besides above)
_________________________________________________________________________________
4. Has your child been HOSPITALIZED? (explain)
_________________________________________________________________________________
5. Has your child had INJURIES with fractures or loss of consciousness?
(explain) __________________________________________________________________________
_________________________________________________________________________________
6. Last VISION Test Date ___________________Last HEARING Test Date ____________________
7. Last DENTIST Visit Date ___________________________
8. Any other members of your family with SERIOUS ILLNESS
recently_______________________________________________________________________________________________________________________________________
9. Any other members of your family history of: ASTHMA ____DIABETES ____
EPILEPSY____
