PARENT INFORMATION
Child’s Name ______Date ______
D.O.B. ______Child’s Social Security Number ______
FATHER / MOTHERName
Address
City
Home Phone
Cell Phone
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 CHILD5. 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 / TelephoneThe child has participated in Early Intervention. Yes No
If YES, please complete the chart below.
Dates of Service / Contact Person / Address / TelephoneThe 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 / TelephoneC. 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 / CommentGet 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