SDSU CHILDREN’S CENTER CHILD’S DEVELOPMENTAL & HEALTH HISTORY · Any health problems of other family members (siblings, parents or extended family members close to the child)

SDSU CHILDREN’S CENTERCHILD’S DEVELOPMENTAL & HEALTH HISTORY

FAMILY BACKGROUND

Child’s Name _______________________________________________ Birthdate ___________________ Sex _______

Place of Birth _______________________________________________ Ethnicity/Race__________________________

Parent Name _______________________________________________________ Living in the home? Yes No

2nd Parent Name ____________________________________________________ Living in the home? Yes No

Siblings (including step or half-sisters and brothers):

Name ____________________________________ Birthdate ________________ Living in the home? Yes No

Name ____________________________________ Birthdate ________________ Living in the home? Yes No

Name ____________________________________ Birthdate ________________ Living in the home? Yes No

Others living in the home:

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Full Term? Yes No Weeks/Months Premature __________________

Place of Work ___________________________________________ Job Title __________________________________

Place of Work ___________________________________________ Job Title __________________________________

Name _______________________________________________ Relationship ____________________ Age ________

Name _______________________________________________ Relationship ____________________ Age ________

Home Language ___________________________________________________________________________________

Other Languages __________________________________________________________________________________

Culutral Practices __________________________________________________________________________________

Has there been any major change in the family unit (i.e. divorce, move, or death)? Please explain

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HEALTH HISTORY

List any chronic health problems, allergies, hospitalizations, physical characteristics (scars, birthmarks) your child has experienced (asthma, seizures, head injuries, bone or joint problems, eye or ear trouble, heart condition):

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Indicate, on the figuresto the right, anypermanent physicalcharacteristics:

Rev. 9/18

Any health problems of other family members (siblings, parents or extended family members close to the child)who are experiencing physical or emotional stress? Please explain:

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BEHAVIOR/PERSONALITY PATTERNS

Describe your child’s personality ______________________________________________________________________

What is your child’s favorite activity? ___________________________________________________________________

In general, how does your child react to anxiety or stressful situations (withdraw, cry, throw tantrums)? ______________

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Please list any fears your child may have _______________________________________________________________

Has your child had much experience relating to adults who are not members of the family? _______________________

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Describe your child’s past childcare experiences _________________________________________________________

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Please check the type of guidance/discipline techniques you use when your child acts inappropriately:

Ignore the problem behaviorTell the child to sit on chairTake away activity/foodRedirect child’s interestScold childSpank child

Reason with childThreaten childSend child to roomOther technique (describe) ______________________

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What comforts your child ___________________________________________________________________________

SLEEPING

Bedtime _________________________ Wake Up ____________________________

Does your child nap? Yes No Nap time: _________________________ to _____________________________

What helps your child prepare to rest/sleep (back rubs, music, bottle, pacificer, etc.) _____________________________

Indications of sleepiness ____________________________________________________________________________

Any concerns about your child’s sleep habits? ____________________________________________________________

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EATING

Does your child: Need to be fed? Yes No Feed himself? Yes No

Use a spoon? Yes No Use a cup? Yes No

List any food allergies or preferences (please fill out a food allergy or preferences form if you child has specific nutritional

needs___________________________________________________________________________________________

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Any concerns regarding eating? ______________________________________________________________________

DIAPERING/TOILET HABITS

Is your child in diapers? Yes No Pull-ups? Yes No

Underwear? Yes No Recently trained? Yes No

Frequency per day of: bowel movements ____________________________ urination ___________________________

Is your child prone to diaper rash or skin allergies? _______________________________________________________

PARENT GOALS/COMMENTS

Please list your hopes for your child while he/she is here at our Center:

1) ______________________________________________________________________________________________

2) ______________________________________________________________________________________________

3) ______________________________________________________________________________________________

Additional comments or concerns: _____________________________________________________________________

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List anywords familiar to your child to describe:

Bowel Movement _______________________________________Urination ___________________________________

Any concerns regarding diapering/toileting? ____________________________________________________________

CELEBRATING FAMILY TRADITIONS

Families are invited to share and explore holiday and cultural practices with the children that represents their families.

Any cultural practices you would like to share with your child’s class? _________________________________________

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