DAILY ROUTINES (*
For infants and preschool-age children only
)
DEVELOPMENTAL HISTORY (
*
For infants and preschool-age children only
)
STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CHILD’S NAME SEX BIRTH DATE
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
BEGAN TALKING AT
*
MONTHS
TOILET TRAINING STARTED AT
*
MONTHS
WALKED AT
*
MONTHS
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT COLDS?
■■ YES ■■ NO
WHAT TIME DOES CHILD GET UP?
*
DOES CHILD SLEEP DURING THE DAY?
*
DIET PATTERN:
(What does child usually
eat for these meals?)
ANY FOOD DISLIKES?
WORD USED FOR “BOWEL MOVEMENT”
*
PARENT’S EVALUATION OF CHILD’S HEALTH
PARENT’S EVALUATION OF CHILD’S PERSONALITY
HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
PARENT’S SIGNATURE DATE
LIC 702 (8/08) (CONFIDENTIAL)
WORD USED FOR URINATION
*
IS CHILD TOILET TRAINED?
*
■■ YES ■■ NO
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
■■
YES
■■
NO
IF YES, NAME OF DOCTOR:
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
■■ YES ■■ NO
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
IF YES, AT WHAT STAGE:
*
ARE BOWEL MOVEMENTS REGULAR?*
■■ YES ■■ NO
ANY EATING PROBLEMS?
WHAT IS USUAL TIME?
*
BREAKFAST
LUNCH
DINNER
WHEN?
*
HOW LONG?
*
WHAT ARE USUAL EATING HOURS?
BREAKFAST ________________________
LUNCH_____________________________
DINNER
WHAT TIME DOES CHILD GO TO BED?
*
DOES CHILD SLEEP WELL?
*
HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
■■ Chicken Pox
■■ Asthma
■■ Rheumatic Fever
■■ Hay Fever
■■ Diabetes
■■ Epilepsy
■■ Whooping cough
■■ Mumps
■■ Poliomyelitis
■■ Ten-Day Measles
(Rubeola)
■■ Three-Day Measles
(Rubella)
DATES DATES
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
DOES CHILD USE ANY SPECIAL DEVICE(S):
■■
YES
■■
NO
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?
■■
YES
■■
NO
IF YES, WHAT KIND:
IF YES, WHAT KIND:
