My Preschool Child
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1
2My Preschool Child
Ferguson-Florissant School District
Child's Name _________________________________________ Birth date_____________ Age _________
Child’s Nickname _____________________________________ Sex ____________
Father/Guardian
Mother/Guardian
Previous educational program and location ___________________________________________________
The following information will help us plan the best program for your child.
Developmental and Health Information
Walked at _________________ mon/yrs. of age
Birth weight
_____________________
Talked in single words at _________ mon/yrs. of age
Current weight _____________________
Put 2 words together at ___________ mon/yrs. of age
Current height _____________________
Is child still learning to use the toilet? yes ___ no____ Date of child’s last dental exam _____________
Learned to use the toilet at _______ mon/yrs. of age
Date of child’s last physical exam ___________
Was there difficulty during pregnancy, labor or delivery? _____ Explain__________________________
Was your child a premature baby? Yes _____ No _____ If yes, how many weeks early? ___________
Has your child had any illness with very high fever? (104° longer than 2 days) Yes_______ No______
If yes, please explain _______________________________________________________________________
Has your child been hospitalized since birth for any reason? Yes _________ No _________
If yes, state reason _________________________________________________________________________
Does your child have a current medical condition? ________ Explain ____________________________
Time child regularly goes to bed at night ___________ Number of hours of sleep each night ________
List any concerns you have about your child's general growth or development
______________________________
________________________________________________________________________________________________________________________
Language Development
My child:
Yes
Sometimes
No
Understands spoken language well
____
____
____
Is able to follow directions
____
____
____
Speaks clearly; is easily understood by new person
____
____
____
Expresses needs adequately
____
____
____
Is able to express ideas clearly
____
____
____
Asks questions
____
____
____
Remembers past experiences
____
____
____
Looks at books
____
____
____
Looks at pictures you point to in books
____
____
____
What is your child's favorite book?
OVER
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