Developmental History And Background Information Form
ADVERTISEMENT
1
2DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
Regulations for licensed child care facilities require this information to be on file to address the needs
of children while in care.
CHILD'S NAME ___________________________________
DATE OF BIRTH _____________
*Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY
Age began sitting ________ crawling ______
walking _________ talking ____________
*Does your child pull up? ________ *Crawl? ______ *Walk with support? _______
Any speech difficulties?
Special words to describe needs
Language spoken at home _______________________ *Any history of colic? __________________
*Does your child use pacifier or suck thumb? _____________ *When? _______________________
*Does your child have a fussy time? ____________________
*When? _______________________
*How do you handle this time?
HEALTH
Any known complications at birth?
Serious illnesses and/or hospitalizations:
Special physical conditions, disabilities:
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions:
Regular medications:
EATING HABITS
Special characteristics or difficulties:
*If infant is on a special formula, describe its preparation in detail
Favorite foods:
Foods refused:
* Is your child fed held in lap?
High chair?
* Does your child eat with spoon?
Fork?
Hands?
TOILET HABITS
*Are disposable or cloth diapers used?
*Is there a frequent occurrence of diaper rash?
*Do you use: oil
powder
lotion
other
*Are bowel movements regular?
how many per day?
*Is there a problem with diarrhea?
constipation?
*Has toilet training been attempted?
*Please describe any particular procedure to be used for your child at the center
What is used at home? pottychair? _______ special child seat? _________ regular seat? _________
How does your child indicate bathroom needs (include special words): _________________________
Is your child ever reluctant to use the bathroom? ___________________________________________
Does the child have accidents? _________________________________________________________
Page 1 of 2
GCCDevelopmentalHistotry20050701
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business