Child’s Health History
Child’s Name______Birth Date______
A. Health
1. Is your child generally healthy? Y N
2. Is your child taking any medications? (Please include over the counter medications and supplements) Y N
If yes, please list medications and conditions.
______
______
______
3. In one year, does your child have as many as three ear infections? Y N
4. Do you have concerns about your child’s hearing? Y N
5. In a year, does your child usually have more than three colds or sore throat infections with a fever? Y N
6. Are you concerned about your child’s eyes or vision? Y N
7. Has your child been seen by a medical specialist? Y N
If yes, who?______
Why?______
8. What arrangements have you made for the care of your child should he/she becomes ill while attending All Saints Academy Child Care Center?______
______
______
9. Does you child have any special needs or challenges? Y N
If yes, please describe.______
______
10. Has your child ever been hospitalized? Y N
If yes, please describe.______
______
11. Has your child had any serious illness, accidents or poisonings? Y N
If yes, please describe.______
______
12. Does your child chew unusual things such as pencils, chalk, cribs, paint chips, plaster, or hair? Y N
13. Has your child been affected by any of the following: (If yes, please circle)
Premature birth Trouble breathing at birth
Birth injury or defect Head Injury
Convulsions or seizures
14. Does your child have allergies? Y N
If yes, please describe allergen and how allergic reaction presents in your child. (Hives, drug/food intolerance, vomiting, wheezing, asthma) ______
______
______
If yes, does your child have prescription medication that will be kept at All Saints Academy Child Care Center? (Epi-Pen or other medications?)
______
______
B. Developmental History
1. How do you comfort your child? ______
______
2. What are your child’s favorite toys? ______
______
3. What are your child’s favorite activities? ______
______
4. What language is spoken in your home? ______
______
C. Sleeping
1. Do you have any special ways of helping your child go to sleep? Y N
If yes, please describe.______
______
2. Does your child cry when going to sleep? Y N
3. What is your child’s present sleep schedule?
Night time From_____to_____ A.M. Nap From_____to_____ P.M. Nap From_____to_____
4. Does your baby prefer to sleep on his/her ____stomach ____side or ____back?
5. Does your child need a ____pacifier ____ blanket or ____toy for nap time?
D. Feeding (Infants only)
1. Is your baby breast fed? Y N
2. Is your baby bottle fed? Y N If yes, please list the type of formula.______
3.Please describe your child’s current nutrition schedule:
Fluid / Amount (oz) / Time / Solid / Amount (tbs.) / Time4.Does your baby need to be burped? Y N
E. Feeding (Preschool and Toddlers Only)
1. What is your child’s present eating schedule: (specify amount)
Breakfast / Lunch / SnackMain Course
Fruits/ Juices
Vegetables
Dairy
2. Has your child had any feeding problems? Y N
If yes, please describe.______
______
F. Toilet
1. How frequently does your child have a B.M.?______Appearance of B.M? ______
2. Is your child toilet trained? Y N
3. What word does your child use for: Urination?______Bowel Movement? ______
4. Does he/she use a potty chair? Y N
5. Does your child frequently have diaper rash? Y N If yes, how is it treated? ______
Tdrive/ASA Forms/New Prospective Parents Forms