Form-Child/Family Personal History

Child's Name

Height

Weight

Birth Date

With whom does your child live?

Father/Guardian Name

Mother/Guardian Name

Brother(s) Name(s)

Sister(s) Name(s)

Other Members of the household (list):

Has your child been cared for by anyone else?

Has your child been cared for by anyone other than parents?

If your child has attended another child care, please name and list for how long.

Please note if your child has any health or other issues requiring special attention that you feel we should be aware of and note any special measures you would like us to take:

My child has his/her own room?

Room Comments?

My child watches TV

If yes how often?

If yes what shows?

Does your child have playmates?

Is your child toilet trained?

What words does your child use when wanting to use bathroom?

Does your child need help dressing?

Does your child need help undressing?

Does your child have any allergies?

If yes, please list allergies:

How can you tell if the child is having an allergic reaction?

Please Explain:

Does your child have any special dietary needs?

If yes, please list:

Does your child have any habits (nail biting, thumb sucking, etc.) or other issues that we should be aware of?

If yes, please explain:

Does your child have any favorite foods?

If yes, please list:

Does your child have any favorite songs or games?

If yes, please list:

Does your child have any favorite toys or stuffed animals?

If yes, please list: