Lic 702 Form - Child'S Preadmission Health History - Parent'S Report
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1STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
CHILD’S NAME
SEX
BIRTH DATE
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY (
For infants and preschool-age children only )
*
WALKED AT
BEGAN TALKING AT
TOILET TRAINING STARTED AT
*
*
*
MONTHS
MONTHS
MONTHS
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
DATES
DATES
■ ■
■ ■
■ ■
Chicken Pox
Diabetes
Poliomyelitis
■ ■
■ ■
■ ■
Ten-Day Measles
Asthma
Epilepsy
(Rubeola)
■ ■
■ ■
Rheumatic Fever
Whooping cough
■ ■
Three-Day Measles
■ ■
■ ■
(Rubella)
Hay Fever
Mumps
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
■ ■
■ ■
HOW MANY IN LAST YEAR?
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
YES
NO
DOES CHILD HAVE FREQUENT COLDS?
*
DAILY ROUTINES (
For infants and preschool-age children only )
WHAT TIME DOES CHILD GET UP?
*
WHAT TIME DOES CHILD GO TO BED?
DOES CHILD SLEEP WELL?
*
*
DOES CHILD SLEEP DURING THE DAY?
*
HOW LONG?
WHEN?
*
*
DIET PATTERN:
BREAKFAST
WHAT ARE USUAL EATING HOURS?
(What does child usually
BREAKFAST ________________________
eat for these meals?)
LUNCH
LUNCH_____________________________
DINNER
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
*
*
IS CHILD TOILET TRAINED?
*
IF YES, AT WHAT STAGE:
*
ARE BOWEL MOVEMENTS REGULAR?
WHAT IS USUAL TIME?
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
WORD USED FOR URINATION
*
WORD USED FOR “BOWEL MOVEMENT”
*
PARENT’S EVALUATION OF CHILD’S HEALTH
IF YES, NAME OF DOCTOR:
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
DOES CHILD USE ANY SPECIAL DEVICE(S):
IF YES, WHAT KIND:
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?
IF YES, WHAT KIND:
■ ■
■ ■
■ ■
■ ■
YES
NO
YES
NO
PARENT’S EVALUATION OF CHILD’S PERSONALITY
HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
PARENT’S SIGNATURE
DATE
LIC 702 (8/08) (CONFIDENTIAL)
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