Child’s Name: __________________________________ Date of Birth: _______________
What would you like us to call your child? __________________________________________
Age child began sitting: ________ crawling ________ walking _______ talking _______
Does child: pull up crawl walk with support
Times child is fussy: ___________________________________________________________
How do you handle these fussy times? _____________________________________________
With whom does child reside? ____________________________________________________
Who else lives in the home (siblings, extended family, pets)? ____________________________
What does child call family members? ________________________________________________
Language spoken at home: ________________________________________________________
Are books read in languages other than English? _______________________________________
Are there words in your home language that we should know?______________ _____________
Please tell us about any cultural family customs, rituals or traditions that will help us make your child’s experience
more meaningful:
Serious illnesses or hospitalizations (describe)?
Any history of colic?
Special physical conditions, disabilities, or allergies (describe)?
Is your child presently or ever been diagnosed with a special need? ____________________________
If so, is he/she receiving any special services? _______________________________________________
Regular medications? ___________________________________________________________________
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
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? ___________________
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: ________________
What time does child go to bed at night: _______________awake in morning: _________________
Are there any sleep/wake time rituals? If so, please describe:
Has child had any experience playing with children? If so, please describe.
Is child: friendly aggressive shy withdrawn
Reaction to strangers? ____________________
Have you had any previous child care experience? yes no
If yes, did it meet your needs and expectations? Explain: _____________________________________
Prefers to play: alone in small groups
Favorite toys and activities? _________________________________________________________
Is child frightened by: animals rough children loud noises dark other
Explain: ________________________________________________________________________
How do you comfort your child?_____________________________________________________
How does your child prefer to be held? ________________________________________________
Please describe by approximate time your child
s current daily activities (e.g., awakening, eating, time out of crib,
napping, toilet habits, fussy time, bedtime):
Do you have ideas about parenting that would help us to better care for your child as an individual?
What do you, as a family, hope to get out of this child care experience?
(Parent’s/Guardian’s Signature)
(Parent’s/Guardian’s Signature)
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