Wareham Child Care 508-295-1734 Warehamchildcare.org DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION Regulations for licensed child care facilities require this information to be on file to address the needs of children while in care. CHILD'S NAME _ ___________________________________DATE OF BIRTH _____________ *Note: Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child. DEVELOPMENTAL HISTORY Age began sitting ________ crawling ----------- walking -------------- talking ---------------- *Does your child pull up? ______ __ *Crawl? --------- *Walk with support? --------- Any speech difficulties? ______________________________________________________________ Special words to describe needs ________ Language spoken at home: _________________________ __ * Any history of colic? _______________ *Does your child use pacifier or suck thumb? ------------------- *When? ------------------------------- *Does your child have a fussy time? __________ __________ *When? --------------------------------- *How do you handle this time ?_ __________________________________________________________ HEALTH Any known complications at birth? ______________________________________________________ Serious illnesses and/or hospitalizations: ____________________________________________________ Special physical conditions, disabilities: __________________________________________________ Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: __________________________ _____________________________________________________________________________________ Regular medications: ___________________________________________________________________ EATING HABITS Special characteristics or difficulties: ______________________________________________________ Favorite foods : ________________________________________________________________________ Foods refused: ______________________________________________________________________ * Is your child fed held in lap? _______ High chair? ________ * Does your child eat with spoon? Fork? ________________ Hands? _________________ TOILET HABITS *Are disposable or cloth diapers used? _______________________ *Is there a frequent occurrence of diaper rash? ____________________________________________ *Do you use: oil ________ powder ________ lotion ________ other ____________________ *Are bowel movements regular? ______ how many per day? ______ *Is there a problem with diarrhea? ______ constipation ? _________ *Has toilet training been attempted? _________ *Please describe any particular procedure to be used for your child at the center What is used at home? pottychair ? ________ special child seat? _________ regular seat? _________ How does your child indicate bathroom needs (include special words): Is your child ever reluctant to use the bathroom? ___________________________________________ Does the child have accidents? __________________________________________________________ SLEEPING HABITS *Does your child sleep in a crib? ----------- Bed? ---------- Does your child become tired or nap during the day (include when and how long)? ____________When does your child go to bed at night? and get up in the morning? Describe any special characteristics or needs (stuffed animal, story, mood on walking etc) ----------- SOCIAL RELATIONSHIPS How would you describe your child: _____________________________________________________ _ Previous experience with other children/day care: _____________________________________________ Reaction to strangers: _________________________ Able to play alone: ______________________ Favorite toys and activities: ______________________________________________________________ Fears (the dark, animals, etc): ____________________________________________________________ How do you comfort your child: _________________________________________________________ _ What is the method of behavior management/discipline at home: ________________________________ _ What would you like your child to gain from this childcare experience? ____________________________ DAILY SCHEDULE: Please describe your child's schedule on a typical day. _______________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Is there anything else we should know about your child? _________________________________________ Parent/Guardian Signature: _________________________________________ Date: ____________ |