Child Information
Child’s Name
What would you like us to call your child?
Date of Birth
Date of Birth
Developmental History
Type of Birth
Complications
Age Child began sitting:
Times child is fussy
How do you handle these fussy times?
Family Information
With whom does child reside?
Who else lives in the home (siblings, extended family, pets)?
What does child call family members?
Language(s) 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
Health/Development
Serious illnesses or hospitalizations (describe)?
Any history of colic?
Special physical conditions, disabilities, or allergies (describe)?
Is your child presently or even 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
Is your child/family vegetarian?
Does your family have any specific requirement of food based on cultural or religious beliefs?
Please confirm any specific requirements (eg must not eat egg or egg products)
Any food allergies?
Have solid foods been introduced?
Please Specify
Foods Refused
Favourite foods
Child Eats:
Specify Other
Child eats with
Specify Other
Toileting/Diapering Habit
Is there frequent diaper rash?
Do you use:
Specify Other
Does child wear:
Are bowel movements regular? How often?
Is there a problem with diarrhea / constipation
Is your child toilet trained? (Yes/No)If yes, when did you begin?
What is used at home?
Word used for urination:
Word used for bowle movement:
Does your child have accidents?
Sleeping Habits
Does child sleep in:
Does child sleep on:
Times child takes naps?
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:
Social Relationships
Has child had any experienece playiing with children? If so, please describe:
Is child:
Reaction to strangers?
Have you had any previous child care experienece?
Favourite toys and activities?
How do you comfort your child?
How does your child prefer to be held?
What is your style of disciplining?
Daily Schedule
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). If your child does not have a strict daily schedule, please let us know that and we will work with you to develop one with you.
Parenting psychology
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 Name
Date
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