Child's Name__________________________________________________________________

Please answer the following questions as best you can to help the staff
get to know your child.

Experience With Others:

What are some of the ways in which your child plays at home?_____________

_________________________________________________________________________

Does your child play with children from other families?__________________

How?_____________________________________________________________________

Does your child usually get his/her own way with other children?_________

If not, how does he/she react?___________________________________________

Is the entire family together for any time during the day?_______________

Eating Habits:

At what time does your child eat breakfast?____________ Lunch?___________

Dinner?______________ Between meal snacks?_______________________________

Does your child feed himself/herself?____________________________________

What is your child's general attitude toward eating?_____________________

If your child refuses to eat, how is this handled and by whom?___________

_________________________________________________________________________

Favorite foods __________________________________________________________

Disliked foods __________________________________________________________

Food allergies __________________________________________________________

Sleep Habits:

Has own room __________ Shares room with other children___________________

Room with parents _______________ At night sleeps from ________ to _______

Average sleeping hours____________ Attitude towards going to bed _________

__________________________________________________________________________

If there is difficulty, how is this handled?______________________________

__________________________________________________________________________

Habits associated with going to bed ______________________________________

Does your child wet the bed at night?________ During naptime? ____________

If so, how is this handled? ______________________________________________

Toilet Habits:

Does your child take himself/herself to the bathroom? ____________________

Time of bowel movement ___________ Regular? ___________ Constipated? _____

Does your child tell you when he/she needs to go to the toilet and go

willingly? _______________________________________________________________

Can your child mamnage his/her clothes at the toilet? ____________________

What word does your child use for urinating? ______________ BM? __________

Speech and Physical Growth:

Does your child talk well? _____ Fairly well? _____ Not very well ________

Not at all? ______ Does anyone read to your child? _______________________

How regularly? ___________ At what age did your child creep? _____________

Crawl? _________ Walk _________

Would you describe your child as active? _______ Quiet? ______ Thin?_____

Average weight? ________ Heavy? _______ Tall? ______ Average height?_____

Short? ______ Friendly? ________ Unfriendly?___________

Please supply any other information you think we should have about your
child.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

________________________________________ Parent /Guardian Signature

________________________________________ Parent/ Guardian Signature

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