Child’s Developmental Toddler/Preschool History

Child's Name ______________________________Nickname______________________________     

DOB _________  Gender: M/F 

Health

1. Is your child well most of the time? Yes/No

2. Is your child taking any medications now? (Including aspirin, laxatives, vitamins, etc.) Yes/No

If yes what?  _________________________ Why? _________________________________

3. In a year, has your child had as many as 3 ear infections? Yes/No

4. Are you concerned about your child's hearing? Yes/No

5. In a year, does your child usually have more than 3 colds or sore throat infections with a fever? Yes/No

6. Are you concerned about your child's vision? Yes/No

7. Has your child been seen by a medical specialist? Yes/No   If yes, who: _________________________________________________________________________________

Why?_________________________________________________________________________________

8. Does your child have any handicaps? Yes/No              If yes, describe: _________________________________________________________________________________

9. Other illnesses or diseases or allergies? Yes/No       If yes, what? _________________________________________________________________________________

10. Does your child have any contagious illnesses that could impact other children or staff (malaria, Hepatitis A, Hepatitis B, HIV, AIDS, etc.)? Yes/ No     If yes, what? _________________________________________________________________________________

11. Has your child has any of the following? (Please circle)             

premature birth, trouble breathing at birth, birth injury, head injury convulsions/seizures, allergies (eczema, hives, drug, peanut, milk, fruits, food intolerance, hay fever, wheezing, asthma, insect stings, seasonal)

Describe: _________________________________________________________________________________

12. What arrangements have you made for the care of your child should he/she become ill at the center? _________________________________________________________________________________

Developmental History

At what age did your child begin to walk? __________talk?__________

How do you comfort your child? _________________________________________________________________________________

What are your child's favorite toys/activities? _________________________________________________________________________________

What language(s) is spoken in your home? _________________________________________________________________________________

Has your child been in a group child care setting previously, and what were his or her reactions?_________________________________________________________________________________

How does your child react to new people and situations? _________________________________________________________________________________

What kinds of things can your child do by him/herself? (feeding, dressing alone, washing hands, using the toilet, etc.) _________________________________________________________________________________

Does your child have any behavioral problems? _________________________________________________________________________________

How do you handle them? _________________________________________________________________________________

Are you aware of any anxieties or fears that your child may have? _________________________________________________________________________________

Circle the words that best describe your child:   confident, loving, leader, fearful, insecure, anxious, follower, responsible, self-reliant, cooperative

Toileting/Sleeping

Is your child toilet trained? Yes/No

What word does your child use for urination? ___________ bowels? _________

Can he/she easily manage the clothing worn? Yes/No

What is your child's current sleeping schedule?

Night time: from _____ to _____ Nap: from _____ to _____

Please tell us anything else that you feel would help us provide a comfortable environment for your child. _________________________________________________________________________________

_________________________________________________________________________________

 

How did you hear about Me Too Preschool? Referred by _____________________________
Newspaper ______________ Drive by  ______ Online search ______ MTP Website _______

Brightstars Website _______ Other ____________________

Child’s Physical Description

Eye color _____________ Hair Color ______________ Weight ________ Height _________

Birthmarks ___________________________ Bone Structure _________________________

Racial/Ethnicity ____________________________

In order to provide the utmost quality care for your child, please tell us anything else that you feel would help us provide a comfortable environment for your child (emotional, physical or behavioral information which would be important for us to know). ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________