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DAYCAREDIVA.COM About Your Child 1. What FOODS does your child especially like? ___________________________________________________ 2. Especially DISLIKE? _____________________________________________________________ 3. Favorite toys, games, activities? ______________________________________________________________ 4. Is your child TOILET TRAINED? ______ What words does your child use for toilet? ________________ 5. How does your child express ANGER or frustration? _____________________________________________ 6. Does your child have any special FEARS? _____________________________________________________ Explain _______________________________________________________________ 7. When your child is upset, what helps to COMFORT him/her? ______________________________________ 8. How do you DISCIPLINE your child? _______________________________________________________ 9. Has your child been taking an afternoon NAP? ___________ If so, how long? ________________ If not, why? _____________________________________________________________________________ 10 . Special toy or blanket for NAP? ____________________________________________________________ 11. Special FAMILY situations? ( such as custody specifications, problems arising from situations, etc.)__________________________________________________________________________ _____________________________________________________________________________ 12. Anticipated ADJUSTMENT problems? _______________________________________________________ _____________________________________________________________________________ 13. Any disorders/developmental (slow, advanced) diagnosed or suspected? ________________ _____________________________________________________________________________ 14. Previous childcare child has attended: ________________________________________________________ 15. Any problems at previous daycares? _________________________________________________________ 16. EXPECTATIONS of Day Care Home ___________________________________________________ _____________________________________________________________________________ 17. Other COMMENTS? _____________________________________________________________________ _____________________________________________________________________________
Health History 1. Child’s name ____________________________________BirthDate _____________ 2. Last Physical Examination ______________________________________________ 3. Illnesses: (please circle)
3. Other ILLNESSES? (besides above) _________________________________________________________ 4. Has your child been HOSPITALIZED? (explain) ________________________________________________ 5. Has your child had INJURIES with fractures or loss of consciousness? (explain) __________________________________________________________________ __________________________________________________________________ 6. Last VISION Test Date ___________________Last HEARING Test Date _________ 7. Last DENTIST Visit Date ___________________________ 8. Any other members of your family with SERIOUS ILLNESS recently?_______________________________________________________________________________________________________________________________________
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