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

Month

Day

Year

Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.

DEVELOPMENTAL HISTORY

Age began:

Sitting

Walking

Talking

Pull up, crawl, walk

*Does your child pull up?

*Does your child crawl?

*Does your child 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 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:

*If infant is on a special formula, describe it's preparation in detail:

Favorite foods:

Foods refused:

*Is your child fed held in lap?

*High chair?

*Does your child eat with a spoon?

*Fork?

*Hands?

TOILET HABITS

*Are disposable or cloth diapers used?

*Is there a frequent occurrence of diaper rash?

*Do you use oil?

*Do you use powder?

*Do you use lotion?

*Do you use another option?

*Are bowel movements regular?

*How many per day?

*Is there a problem with diarrhea?

*Is there a problem with constipation?

*Has toilet training been attempted?

*Please describe any particular procedure to be used for your child at the center:

*Is a pottychair used at home?

*Is a special child seat used at home?

*Is a regular seat used at home?

*How does your child indicate bathroom needs (include special words):

Is your child ever reluctant to use the bathroom?

Does your child have accidents?

SLEEPING HABITS

*Does your child sleep in a crib?

*Does your child sleep in a bed?

Does your child become tired or nap during the day (include when and how long)?

Please note: The American Academy of Pediatrics has determined that placing a baby on his/her back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and unexplained death of a baby under one year of age. If your child does not usually sleep on his/her back, please contact your pediatrician immediately to discuss the best sleeping position for your baby. Please also take the time to discuss your child’s sleeping position with your caregiver.

When does your child go to bed at night?

When does your child get up in the morning?

Describe any special characteristics or needs (stuffed animal, story, mood on waking 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. For infants, please include awakening, eating, time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.

Child's Schedule

Is there anything else we should know about your child?

Parent/Guardian Signature

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Date

Month

Day

Year