Developmental History and Background Information 2021-2022 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.