PARENT INFORMATION

Child’s Name ______Date ______

D.O.B. ______Child’s Social Security Number ______

FATHER / MOTHER
Name
Address
City
Home Phone
Cell Phone
Email
Occupation
Education
Age
Mother’s Maiden Name

A.FAMILY HISTORY

1. With whom does the child live? ______

2. Who is the legal guardian? ______

3. Is there a stepparent living in the home? ______

4. Indicate siblings or other individuals living with the child in the chart below.

NAME / AGE / RELATIONSHIP TO CHILD

5. With whom does the child stay during the day? ______

______

6. Describe any unique family circumstances that have a significant impact on this child’s development: ______

______

7. What holidays does the family celebrate? ______

______

B. MEDICAL INFORMATION

Child’s Birth Weight ______City of Birth ______State of Birth ______

Was the child’s birth a full-term pregnancy with no complications? Yes No, please describe.

______

Were there any complications prior to or immediately following delivery? Yes, please describe. No

______

Who is the child’s regular physician? ______

When was the child’s last physical examination? ______

Who is the child’s regular dentist? ______

When was his/her last dental examination? ______Does your child brush his/her teeth? Yes No

Does your child have frequent colds, sore throats, earaches, etc.? Yes, please describe. No

______

Has your child ever had seizures? Yes When? ______No

The child takes medication on a regular basis. Yes, please describe. No

______

Has your child ever been hospitalized? Yes, please describe. When? ______No

______

______

The child has food or environmental allergies. Yes, please describe. No

______

______

The child has adaptive or medical needs (i.e., glasses, hearing aids, walker, leg braces, wheelchair, feeding tube, specialized seating, prone stander, dietary restrictions, catheter, shunt, etc.). Yes, please describe. No

______

______

Parents and medical records indicate a history of significant health concerns, major childhood illnesses/ disease, or diagnosed syndromes. Yes, please describe. No

______

The child has vision within normal limits. Yes No, please describe.

______

The child’s hearing is within normal limits. Yes No, please describe.

______

Other significant health/nutrition issues not covered in the previous questions.

______

______

The child has received therapy (i.e., speech-language, occupational therapy, orientation and mobility, etc.). Yes No

If YES, please complete the chart below.

Type of Therapy / Dates of Therapy / Contact Person / Address / Telephone

The child has participated in Early Intervention. Yes No

If YES, please complete the chart below.

Dates of Service / Contact Person / Address / Telephone

The child has attended (is attending) a childcare, preschool or Head Start Program. Yes No

If YES, please complete the chart below.

Dates of Service / Contact Person / Address / Telephone

C. DEVELOPMENTAL INFORMATION

Age your child walked ______, talked ______, was toilet trained ______

Was there difficulty in any of the above? Yes, please describe. No

______

Does your child play with other children? Yes, please describe. How often? ______No

______

What is your child’s bedtime? ______Wake-up time? ______

Does your child. . .

Activity / Yes / No / Comment
Get along with other children
Share with others
Play well alone
Eat well
Sleep well
Sleep fitfully
Have night terrors
Resist daytime nap
Wet the bed

D. BEHAVIOR

Circle the terms that apply to your child: friendly, temperamental, follower, shy, sucks thumb/fingers, unresponsive, bites nails, leader, cheerful, explosive, fearful, sullen, babyish, destructive

Does your child have frequent tantrums? Yes, please describe. No

______

Does your child cry easily? Yes, please describe. No

______

How does your child adapt to new situations? ______

What upsets him/her? ______

What calms him/her? ______

What makes him/her happy? ______

Does he/she have any specific fears? Yes, please describe. No

______

How does he/she react when disciplined? ______

E. GENERAL INFORMATION

What is your child’s favorite activity?______

What are his/her favorite toys?______

What are his/her favorite TV shows?______

How much television does he/she watch each day?______Video games? ______

Do you read to your child? Yes How often? ______No

What are his/her favorite stories?______

What are his/her favorite foods? ______

Does he/she use a cup? Yes No Spoon? Yes No Fork? Yes No Knife? Yes No

Does he/she have toileting problems? Yes, please describe. No

______

How does he/she indicate the need to use the bathroom? ______

______

What regular responsibilities does he/she have at home? ______

______

Does your child dress him/herself completely? Yes No, please describe.

______

Can he/she use zippers? Yes No Snaps? Yes No Buttons? Yes No Tie shoes? Yes No

What would you like to see your child accomplish in this program? ______

______

Are there any other things about your child that we should know? Are there any new developments or changes occurring at home (i.e., divorce, new baby, moving, etc.)? ______

______

F. WHAT CONCERNS ARE THERE ABOUT THIS CHILD?

What child is/is not doing: ______

______

How this behavior interferes with the child’s typical daily routines: ______

______

How long this concern has been observed/evident: ______

______

Describe the things that have been done (interventions) to address the concerns listed above: ______

______

______

ECDHS604 Page 1 REV 6/11