Developmental History and Background Information 2022-2023

Child's First Name *

Child's Last Name *

Date of Birth *

Developmental History

Age began sitting *

Age began crawling *

Age began walking *

Age began talking *

Special words to describe needs *

Health

Any known complications at birth *

Special physical conditions, disabilities or ALLERGIES (i.e. asthma, hay fever, insect bites, medicine, food – and reaction) *

Serious illnesses or hospitalizations *

List any regular medications taken *

Eating Habits

Special characteristics or difficulties with eating *

Describe favorite foods *

Foods refused *

Toilet Habits

Has toilet training been *

attempted

completed

Does your child use *

a potty chair

a special seat

a regular toilet

How does child indicate bathroom needs (Include special words)? *

Is your child ever reluctant to use the bathroom? *

Does your child have accidents? *

Sleeping Habits

When does your child get up in the morning and go to bed at night? *

Does child become tired or nap during the day and when and for how long does this occur? *

Describe special characteristics or needs (stuffed animal, story, blankie, mood on waking etc.) *

Social Relationships

How would you describe your child? *

Previous experience with other children/daycare *

Reaction to strangers *

Able to play alone *

Describe your child’s interest in playing with other children *

Favorite toys and activities *

Fears (the dark, animals, thunder, etc.) *

How do you comfort your child? *

What is the method of behavior management/discipline at home? *

Describe your child’s schedule on a typical day *

What would you like your child to gain from this early education experience? *

Is there anything about your race, religion, culture, or family structure that would assist us in better understanding your child? *

Is there anything else you would like us to know about your child? (For example, is your child receiving any special services, i.e. speech, physical or occupational therapy, etc.) *

Language

Child's Dominant Spoken Language *

Child speaks dominant language clearly (check one) *

occasionally

sometimes

mostly

Child understands dominant language (check one) *

occasionally

sometimes

mostly

For children whose dominant language is NOT English: Child speaks English clearly (check one) *

occasionally

sometimes

mostly

For children whose dominant language is NOT English: Child uses spoken English for a variety of purposes (check one) *

occasionally

sometimes

mostly

Is a language other than English spoken at home? *

yes

no

If "yes," what language? *

What is the primary language spoken to the child at home? *

What language does the child use at home? (check one) *

only English

mostly English and sometimes other

mostly other and sometimes English

only other

Please provide additional information about your child, or submit a separate sheet of paper if needed. *

Signature *

Clear

Email Address *

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