CHILD’S PROFILE

Child’s Full Name: __________________________________

Child’s Birth Date: __________________________________

Home Address: ______________________________________

Parent’s Names: _____________________________________

Child’s Physician Name: ______________________________

Health Card #: ______________________________________

Has or does your child have any known health problems? Yes ( ) No ( ). If yes, describe:

Does your child have any known allergies? Yes ( ) No ( ).

If yes, please list:

Special instructions in the event of an allergic reaction:

List communicable diseases your child has had (ex. chicken pox, measles, and mumps)

Are your child’s immunizations up to date? Yes ( ), No ( )

List immunizations recieved and dates:

Is your child prone to: (circle those that apply); stomach upsets, colds, headaches, sore throats, ear aches, other?__________________________________________________

Are there any indications of vision or hearing problems? Yes ( ) No ( )

Has he/she had any recent serious illness? Yes ( ) No ( ).

What is your child’s general health status?

Does your child have any mental or physical disabilities? Yes ( ) No ( ).

If yes, please explain:

Do you have a back up plan if your child is ill and cannot attend day care?

Yes ( ) No ( ).

What is your child’s eating habits? (Times child usually eats, mind trying new things, etc.)

If your child is drinking formula, do they prefer it cold or warm? _________________

Child’s usual dining habits (circle those applicable); High chair, table, uses utensils, bottle, sipper cup, regular cups.

Does your child have a small or large appetite?

What are your child’s favorite foods?

What does your child strongly dislike?

How would you describe your child’s personality?

Does your child have a regular bedtime schedule? Yes ( ) No ( ).

Does your child have any sleep problems? Yes ( ) No ( ). If yes, describe.

If infant, how do you prefer to be placed in the crib (front, back, side). Please circle one.

What time does your child usually go to bed/afternoon nap?

What time do they wake in the morning?

What is their disposition when waking up? i.e, happy, grouchy, clings, slow?

Please list your child’s favorite activities:

Please list your Child’s favorite toys:

Special instructions concerning care, medications or diet not mentioned?

Parent Signature: _________________________________

Date: ______________________________________________

Thank your for taking the time to fill out your childs profile. This helps me understand and accommodate your them personally.

Please fill out an additional profile for each child.