Is your child presently or ever been diagnosed with a special need? ____________________________
If so, is he/she receiving any special services? _______________________________________________
Regular medications? ___________________________________________________________________
EATING HABITS
Special characteristics or difficulties? ______________________________________________
Special diet: _________________________ Formula: _________ Breast Milk: __________
How often
Any food allergies? ____________________________________________________________
Have solid foods been introduced? YES NO
If yes, please identify: ______________________________________________________________
Favorite foods: ________________________ Foods refused: ________________________
Child eats: on lap in high chair other
Child eats with: spoon fork hands other
TOILETING/DIAPERING HABITS
Is there frequent diaper rash? YES NO
Do you use: cream powder lotion other :__________________
Are bowel movements: regular YES NO how often: _____________
Is there a problem with: diarrhea YES NO constipation YES NO
Is your child toilet trained: YES NO If yes, when did you begin? _______________
Any issues with urination: YES NO bowels: YES NO Explain:_________________
What is used at home: potty-chair special seat regular seat
Word used for urination: ____________________ bowel movement: _____________________
Does your child have accidents? yes no If yes, how often/when? ___________________
__________________________________________________________________________________
SLEEPING HABITS
Does child sleep in: crib bed with parents
Does child sleep on: back side stomach
(At center we must use “Back to sleep in accordance with our licensing policies)
Times child take naps? Times: a.m. _________- __________ p.m_________ -_________
Additional napping information?___________________________________
What does child take to bed? ___________________ mood on awakening: ________________
