Infant Health Information and Development History
Please complete this form as completely and as accurately as possible. Feel free to elaborate. All information will be completely confidential. Thank you for your cooperation.
Date ______
Child’s Name ______Birthdate ______
Parents or Guardian ______
Personal History
Child’s Nickname ______Place of Birth ______
Language spoken at home ______
Name and age of siblings’ ______
Previous / other child care arrangements ______
Were you and your child satisfied with these arrangements? ______
______
Eating
Does your child have any food allergies? ______
Any special feeding problems? ______
Is your child Breastfed or bottle fed? ______
Does your child use a bottle? ______cup? ______
Does your child eat unassisted? ______
How has your child been fed? Held in lap? ______High chair? ______
Other ______
Does your child have any favorite foods? ______
Schedule
Describe your child’s schedule ______
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Length of time this schedule has been in use: ______
Any history of colic: ______If so, how is it handled: ______
Does your child have a fussy time? ______
If so, how is it handled? ______
Are there any ways we can help with your child’s schedule? ______
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Diapering
Is your child’s skin highly sensitive? ______
Does your child get frequent diaper rash? ______
What do you use to cope with diaper rash? ______
How frequent are your child’s bowel movements? ______
Is there any frequent diarrhea or constipation? ______
How does your child respond to diapering? ______
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Is there any other information we need to know about diapering?
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Sleeping
At what time does your child go to bed? ______Wake?______
Does your child sleep through the night? ______How often do they wake up? _____
How does your child show they are tired? ______
Does your child have their own bedroom? ______
Does your child sleep in a crib, bassinet, swing, etc? ______
What does your child take to bed with them? ______
What is your child’s mood upon awakening? ______
What time(s) does your child nap? ______
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Do you have a special way to help your child go to sleep? ______
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Does your child use a pacifier or suck their thumb? ______When? ______
Are there any other special instructions or information pertaining to your child’s sleep /
Nap habits? ______
Social Relationships
Has your child had experience in playing with other children? ______
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Is your child usually friendly? ______Shy? ______Withdrawn? ______
Aggressive? ______Other? ______
How does your child get along with their siblings? ______
How does your child relate to other adults? ______
Does your child know any other children attending CNS? ______
Do you feel your child will adjust easily to the child care situation? ______
Does your child prefer to be entertained or is he/she content entertaining themselves?
______
What makes your child upset? ______
How does your child show his/her feelings? ______
Does anything frighten your child? ______
What are your child’s favorite activities at home? ______
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Does your child like to be read to? ______
Does your child like music? ______
Does your child enjoy being outdoors? ______
Health
Doctor’s Name ______Phone Number ______
Was your child born full term? ______Were there any complications? ______
Has your child been seriously ill or hospitalized? ______
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Does your child have any physical disabilities? ______
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Does your child have any known allergies? ______
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How many colds has your child had in the past year? ______
Does your child usually run a fever when ill? ______How high? ______
Does your child take any medications regularly? ______
Does your child ever have seizures? ______
If so, what do they look like? ______
Has your child any had any childhood illnesses? ______
______
Physical Development
Can your child pull up? ______
Walk by themselves with or without help? ______
Does your child roll over? ______Sit by themselves? ______
Crawl? ______Cruise? ______
General
In what particular ways can we help your child this year? ______
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How do you feel about child-care for your child? ______
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What would you like to see us provide for your child? ______
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Is there anything else we need to know to better care for your child?
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What arrangements have you made for child-care during illness?
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Parent Signature: ______
10/24/16