This may seem like al ong form but it will provide a lot of good information to help me take care of your infant or toddler. If there is any other information you wish to provide me with that will make your child's experience here better please feel free to add sheets of paper or use the back of these pages.
If you have any questions feel free to contact me at 243-1589 or email me at [email protected]. Thank you!
Parent and child name and address:
Name-child Nickname (if any)
name or parent(s) Phone number
Address
Health
Circle all that apply:
Child has/had allergies or special physical condition-describe
Child had a seriuos illness, convulsion, operation, or accident-describe, include occurance date
Child has frequent colds, ear infections, colic, ect...-describe
Meals
Current feeding schedule and length of time on current schedule
Food type circle please
formula strained junior table food milk type-specify
Feeds self _____Yes _____No When eating, child is (circle) held in lap sits in high chair other-specify
Special feeding needs
Food allergies
Favorite foods
foods refused
Updates
Sleep
Current sleep schedule Length of time on current schedule
Falls asleep easily? ____Yes ____No
Takes favorite toy(s) to bed? ____Yes ____No
If yes list toys
Sleeping position _____Back _____Side or stomach (Not recommended) If side or stomach box is checked parent must inial and date to indicate having recieved information on sleeping positions and SIDS.
Diapering/Toileting
diaper type (circle) cloth disposable (diapers provided by parent)
Highly sensative skin? _____Yes _____No
Oil, powder or lotion used? ____Yes ____No If yes please specify product names
Toilet training attempted? ____Yes ____No If yes describe routine
Type of toilet seat used at home? (Cirlce) potty chair Special toilet seat regular toilet seat
Regular bowel movements? ____Yes ____No
toileting problems? ____Yes ____No If yes describe
Verbal communication
Family speaks what language?(circle) English Other-specify
Age child began talking
Child speakd in (circle) Words Sentences
Updates
Comforting
Does your child have a fussy time? ____Yes ____No If yes When?
How is this fussy time handles?
Child likes to be: (circle) Held Sung to Read to Other-specify
Updates
Self Expression
What causes your child to feel angy or frustrated?
What frightens your child and how is it shown?
How does your child express feelings of happiness, enjoyment, ect?
Additional comments:
Updates