Fillable INFANT PERSONAL CARE PLAN DEVELOPMENTAL HISTORY FORM

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INFANT PERSONAL CARE PLAN DEVELOPMENTAL HISTORY FORM

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  • 10 check-boxes
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INFANT PERSONAL CARE PLAN
DEVELOPMENTAL HISTORY FORM
1
Today’s Date: __________________________ Date of Enrollment/Transition: _______________________
Child’s Name: _________________________ Date of Birth: ________________ Age: ________________
Date of Last Physical (for WA State only): _____________________________________________________
What would you like us to call your child?:_____________________________________________________
Parent/Guardian Name: ______________________________________________________________________
Parent/Guardian Name: ______________________________________________________________________
Name of Person Completing Form: ____________________________________________________________
Primary Caregiver: __________________________________________________________________________
Classroom: __________________________________________________________________________________
FAMILY INFORMATION
If parental custody is shared, describe the custody arrangements: ___________________________
Please tell us about cultural family customs, rituals, or traditions that will help us make your
child’s experience more meaningful, including languages spoken at home: ____________________
In the columns below list the names of family
members residing with the child. Please include
siblings, extended relatives, and pets. For each
person listed provide the name the child uses
to address that individual and include ages of
siblings.
Name
How child addresses
this individual? Age
Please list the words used in your
language corresponding to the words in
English. Include additional words in the
blank columns if needed.
I’ll take good care of you
I see that you are crying
Let’s change your diaper
I like your smile
It’s time for your bottle
Time to eat
Time for your nap
Mommy will be back
Daddy will be back
CHILD’S NAME:
Infant Personal Care Plan - Developmental History Form
2
DEVELOPMENTAL HISTORY
Age Child Began: Sitting: _________ Crawling: _______ Standing: ________ Walking with support: _________
Walking independently: ___________________ Cooing: ____________________ Babbling: _______________________
Saying audible words:_________________________ Saying 2 or 3 simple sentences: ____________________________
Do you have developmental concerns about your child?
How does your child communicate his/her needs? ______________________________________________
CHILD’S HEALTH
List medications regularly taken and conditions requiring them: _______________________________
Describe serious illnesses or hospitalizations: _______________________________________________
Describe special physical conditions, disabilities, allergies, or concerns: _________________________
Does your child have a special need?_______________________________________________________
Explain special services and accommodations, which are different from those provided by the
center’s routine program (i.e. exercises, equipment, materials, or special services personnel): ______
Note: For documented medical allergies an Allergy Health Care Plan completed by the child’s medical
provider is required.
CHILD’S NAME:
3
Infant Personal Care Plan - Developmental History Form
NUTRITION PRACTICES AND ROUTINES
How is your child fed? Check all that apply: Breast: Bottle: Cup:
In the corresponding row, provide your child’s feeding details.
Brand Amount Preferred time of day given
Formula/Milk
Breast Milk
Juice
If your baby is exclusively breast fed, please outline your daily plan: __________________________________
If your baby is breast fed or receiving expressed breast milk, how can we support you?____________
List special dietary requests, and restrictions: _________________________________________________
Have solid foods been introduced? Yes No If yes, please identify: __________________________
Food likes and eating preferences: ____________________________________________________________
Child Eats With: Spoon:
Fork: Fingers:
Child is Fed in: Highchair: In Arms: Bouncy Seat: Other: ______________________________
Preferred time of day to feed child:
A.M. A.M. P.M. P.M.
Additional Information: ____________________________________________________________________
CHILD’S NAME:
Infant Personal Care Plan - Developmental History Form
4
SLEEPING ROUTINES
Pre-nap routines/rituals: _____________________________________________________________________
Number of naps daily: ___ From: ______ To: ______ From: _____ To: _____ From: _____ To: ______
Preferred sleep position*: ____________________________________________________________________
At home child sleeps in (Check all that apply: Bassinet: Crib: Bed:
Child’s typical waking behavior/routine: _______________________________________________________
Special sleeping concerns: ____________________________________________________________________
Note: Bright Horizons places infants to sleep on their backs in crib unless a waiver has been signed by the parents
and the child’s physician, stating that the child should be placed in a position other than on his/her back and if
allowed by the state licensing agency. Following the recommendation of the American Academy of Pediatrics, soft
items such as bumpers, stuffed animals (including pacifiers with a stuffed animal attached), blankets and quilts
are not allowed in cribs. The use of sleep or swaddle sacks are recommended for naptime; however, there may be
restrictions on the use of and type of these by the state licensing agency.
COMFORTING CHILD
Position child prefers to be held: ____________________________________________________________
Security object (if any):__________________ Name child uses for object/when needed: ____________
Does your child use a pacier? Yes No If yes, when: ___________________________________
Describe how adults can comfort your child? __________________________________________________
DIAPERING/TOILETING ROUTINES
Please check which type of diapers you will provide: disposable: cloth:
Words used for urination: ___________________________________________________________________
Words used for bowel movement: ____________________________________________________________
CHILD’S NAME:
5
Infant Personal Care Plan - Developmental History Form
SOCIAL RELATIONSHIPS
Has your child had any experience with group care? If yes, please describe: ______________________
How does your child react to new situations and new children and adults? _______________________
Has your child had previous child care experience? If yes, explain how it met, or did not meet,
your expectations? __________________________________________________________________________
Child’s favorite toys and activities: ___________________________________________________________
Does your child have any fears? Explain: ______________________________________________________
ADDITIONAL PERTINENT INFORMATION
To help us care for your child as an individual, please explain your parenting philosophy: _________
Is there additional information you feel is important for the staff to know about your child or
family? ____________________________________________________________________________________
What do you as a family, hope to get out of this child care experience? ___________________________
CHILD’S NAME:
Infant Personal Care Plan - Developmental History Form
6
Sections of this Personal Care Plan will be updated every 3 months or sooner if requested by a
parent/guardian.
Parent/Guardian Signature: Date:
Staff Signature: Date:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
Date of Change: Parent Initials: Staff Initials:
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Completed 8 September 2021

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