Infant/toddler Development And Routine Form

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Infant/Toddler Development and Routine
(birth to 36 months)
Questions about this form? Please call 701-231-8281
We want to provide you with the best care possible. Please help us to get to know your child by filling out this questionnaire. Thank you!
Child's Name:
Room:
Birth Date:
Child's Name:
FAMILY DATA
Parent Marital Status:
Single
Married
Separated
Divorced
Widowed
Household Members:
Name:
Sibling Age:
Relationship:
Name:
Sibling Age:
Relationship:
Name:
Sibling Age:
Relationship:
Child's Race or National Origin:
Native American or Alaskan Native
Asian or Pacific Islander
Hispanic
Black
White
Languages other than English, spoken in the home:
Preferred language I want my child to speak at home:
At child care:
Religious Preference:
Culture is made up of factors in the environment, such as attitudes, values, cherished beliefs, ways of doing things, and child rearing practices.
My cultural preferences include:
DAILY ROUTINE
Sleeping
Please describe your child's usual bedtime routine (including what time and where he/she usually sleeps:
How do you know that your child is sleepy/tired?
Does your child have any difficulties falling asleep?
If yes, what is helpful?
About how many hours of uninterrupted sleep does your child get each night?
Does your child nap?
How many hours on average?
Does your child sleep with a special blanket, toy, pacifier, song?
Do you have any concerns about your child's sleep habits?
If yes, please explain:
Eating
Does your child generally enjoy eating?
Do you consider your child a good eater?
What are some of your child's favorite foods?
Is your child on any special diet?
List any food allergies:
Are there any other food you do not want us to offer your child?
Are there any foods from your home/culture that you would like us to offer your child?
Do you breastfeed your child?
If yes, how often?
What does your child eat with?
Hands
Spoon
Fork
Yes
No
Does your child eat independently?
Breast
Bottle
Tippy Cup
Regular Cup
What does your child use to drink?
What does your child drink?
Breast Milk
Formula
Whole Milk
Skim Milk
Do you have any concerns or questions about your child's eating habits?
If yes, explain:
Toileting
Does your child wear diapers?
If yes, what kind?
Disposable
Cloth
Pull-Ups
If no, does your child use the the toilet regularly?
Please explain:
Families use a variety of words to describe bathroom activities. Indicate the words your family use for:
Urine:
Bowel Movement:
Genital Area:
Do you have any concerns or questions about your child's toileting habits?
If yes, explain:
CCD-ITRoutine - REV 06/2012
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