| Child's Profile Child's Full Name: ______________________________________________________ Child's Birth Date: _____________________________________ Home Address: ____________________________________ ____________________________________ ____________________________________ Parent's Names: _______________________________________________________________ Child's Physician Name: ________________________________________________________ Child's Physician phone number:__________________________________ Health Card Number: ____________________________________ 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, mumps) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Are your child's immunizations up to date? Yes_____ No _____ Is your child prone to:____ Stomach upsets ____colds _____ headaches _____ sore throats _____ ear aches 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 daycare? Yes_____ No _____ What is your child's eating habits? (Times child usually eats, mind trying new things, etc.) _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Child's usual dining habits High chair_____ table _____ uses utensils _____sipper cup _____ regular cup _____ Does your child have a small or large appetite? Small ____ Large ____ Average____ What does your child strongly dislike? _______________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ How would you describe your child's personality? ____________________________________________________________ _____________________________________________________________________________________________________ Does your child have a regular nap schedule? yes ____ no _____ If yes, what is the regular schedule?_________________________________________________________________________ ______________________________________________________________________________________________________ Does your child have any sleep problems? yes_____ no_____ If yes, describe ________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ What is their disposition when waking up? Happy_____ Grouchy _____ Cling _____ Slow _____ Please list your child's favorite activities: ____________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Please list your child's favorite toys:_________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Special instructions concerning care, medications or diet not mentioned? ___________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Date ______________________________ Thank you for taking the time to fill out your child's profile. This helps me understand and accommodate your child. Please fill out an additional profile for each child. |
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