SDSU CHILDREN’S CENTERCHILD’S DEVELOPMENTAL & HEALTH HISTORY
FAMILY BACKGROUND
Child’s Name _______________________________________________ Birthdate ___________________ Sex _______
Place of Birth _______________________________________________ Ethnicity/Race__________________________
Parent Name _______________________________________________________ Living in the home? Yes No
2nd Parent Name ____________________________________________________ Living in the home? Yes No
Siblings (including step or half-sisters and brothers):
Name ____________________________________ Birthdate ________________ Living in the home? Yes No
Name ____________________________________ Birthdate ________________ Living in the home? Yes No
Name ____________________________________ Birthdate ________________ Living in the home? Yes No
Others living in the home:
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Full Term? Yes No Weeks/Months Premature __________________
Place of Work ___________________________________________ Job Title __________________________________
Place of Work ___________________________________________ Job Title __________________________________
Name _______________________________________________ Relationship ____________________ Age ________
Name _______________________________________________ Relationship ____________________ Age ________
Home Language ___________________________________________________________________________________
Other Languages __________________________________________________________________________________
Culutral Practices __________________________________________________________________________________
Has there been any major change in the family unit (i.e. divorce, move, or death)? Please explain
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HEALTH HISTORY
List any chronic health problems, allergies, hospitalizations, physical characteristics (scars, birthmarks) your child has experienced (asthma, seizures, head injuries, bone or joint problems, eye or ear trouble, heart condition):
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Indicate, on the figuresto the right, anypermanent physicalcharacteristics:
Rev. 9/18
Any health problems of other family members (siblings, parents or extended family members close to the child)who are experiencing physical or emotional stress? Please explain:
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BEHAVIOR/PERSONALITY PATTERNS
Describe your child’s personality ______________________________________________________________________
What is your child’s favorite activity? ___________________________________________________________________
In general, how does your child react to anxiety or stressful situations (withdraw, cry, throw tantrums)? ______________
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Please list any fears your child may have _______________________________________________________________
Has your child had much experience relating to adults who are not members of the family? _______________________
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Describe your child’s past childcare experiences _________________________________________________________
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Please check the type of guidance/discipline techniques you use when your child acts inappropriately:
Ignore the problem behaviorTell the child to sit on chairTake away activity/foodRedirect child’s interestScold childSpank child
Reason with childThreaten childSend child to roomOther technique (describe) ______________________
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What comforts your child ___________________________________________________________________________
SLEEPING
Bedtime _________________________ Wake Up ____________________________
Does your child nap? Yes No Nap time: _________________________ to _____________________________
What helps your child prepare to rest/sleep (back rubs, music, bottle, pacificer, etc.) _____________________________
Indications of sleepiness ____________________________________________________________________________
Any concerns about your child’s sleep habits? ____________________________________________________________
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EATING
Does your child: Need to be fed? Yes No Feed himself? Yes No
Use a spoon? Yes No Use a cup? Yes No
List any food allergies or preferences (please fill out a food allergy or preferences form if you child has specific nutritional
needs___________________________________________________________________________________________
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Any concerns regarding eating? ______________________________________________________________________
DIAPERING/TOILET HABITS
Is your child in diapers? Yes No Pull-ups? Yes No
Underwear? Yes No Recently trained? Yes No
Frequency per day of: bowel movements ____________________________ urination ___________________________
Is your child prone to diaper rash or skin allergies? _______________________________________________________
PARENT GOALS/COMMENTS
Please list your hopes for your child while he/she is here at our Center:
1) ______________________________________________________________________________________________
2) ______________________________________________________________________________________________
3) ______________________________________________________________________________________________
Additional comments or concerns: _____________________________________________________________________
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List anywords familiar to your child to describe:
Bowel Movement _______________________________________Urination ___________________________________
Any concerns regarding diapering/toileting? ____________________________________________________________
CELEBRATING FAMILY TRADITIONS
Families are invited to share and explore holiday and cultural practices with the children that represents their families.
Any cultural practices you would like to share with your child’s class? _________________________________________
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