Developmental History and Background Information 2020-2021 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 * reCAPTCHA If you are human, leave this field blank.