About Your Child

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? ______

10. Special toy or blanket for nap? (excluding infants)______

11. I have ____ brothers & ____ sisters, their names and ages are: ______

______

12. Special family situations? ______

13. Anticipated adjustment problems? ______

______

14. Any disorders/developmental (slow, advanced) diagnosed or suspected? ______

______

15. Previous childcare child has attended: ______

16. Any problems at previous daycares? ______

17. Expectations of Day Care Home ______

______

18. Other COMMENTS? ______

______

Health History

Child’s name ______Birth Date:______

Food allergies: ______

Medicine allergies: ______

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

Other Illnesses? (not listed above) ______

Has your child been hospitalized? (explain) ______

Has your child had injuries with fractures or loss of consciousness? (explain) ______

______

Any other members of your family history of: ASTHMA ____DIABETES ____ EPILEPSY____

Updated Vaccinations: yes / no

TB Test: positive / negative