CHILD’S PREADMISSION HEALTH HISTORY - PARENT/AUTHORIZED REPRESENTATIVE REPORT
CHILD’S NAME
*
First Name
Last Name
SEX
*
Please Select
Male
Female
N/A
BIRTHDATE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
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PARENT / AUTHORIZED REPRESENTATIVE NAME
*
First Name
Last Name
DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?
*
Please Select
Yes
No
Do you need to add an additional Parent / Authorized Representative living in home with child?
*
Yes
No
PARENT / AUTHORIZED REPRESENTATIVE NAME
*
First Name
Last Name
DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?
*
Please Select
Yes
No
IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
*
Yes
No
DATE OF LAST PHYSICAL/ MEDICAL EXAMINATION
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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DEVELOPMENTAL HISTORY
For infants and preschool-age children only
WALKED AT
*
Please Select
6th Month
7th Month
8th Month
9th Month
12th Month
13th Month
14th Month
15th Month
BEGAN TALKING AT
*
Please Select
6th Month
7th Month
8th Month
9th Month
12th Month
13th Month
14th Month
15th Month
TOILET TRAINING STARTED AT
*
Please Select
1st Year
2nd Year
3rd Year
4th Year
PAST ILLNESSES
Check illnesses that child has had and specify approximate dates of illnesses:
Rows
Check
Dates
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever
Diabetes
Epilepsy
Whooping Cough
Mumps
Poliomyelitis
Ten-Day Measles (Rubeola)
Three-Day Measles (Rubella)
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
*
Type NONE if there not any serious / severe illnesses / accidents.
DOES CHILD HAVE FREQUENT COLDS?
*
Yes
No
HOW MANY IN LAST YEAR?
*
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
*
Type NONE if there are no allergies staff should be aware of.
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DAILY ROUTINES
For infants and preschool-age children only
WHAT TIME DOES CHILD GET UP?
*
Hour Minutes
AM
PM
AM/PM Option
WHAT TIME DOES CHILD GO TO BED?
*
Hour Minutes
AM
PM
AM/PM Option
DOES CHILD SLEEP WELL?
*
Please Select
Yes
No
DOES CHILD SLEEP DURING THE DAY?
*
Please Select
Yes
No
WHEN?
*
HOW LONG?
*
DIET PATTERN:
*
Rows
What does child usually eat for these meals?
What are the usual eating hours
BREAKFAST
LUNCH
DINNER
ANY FOOD DISLIKES?
*
Type NONE if there is no food dislikes.
ANY EATING PROBLEMS?
*
Type NONE if there is no eating problems.
IS CHILD TOILET TRAINED?
*
Yes
No
AT WHAT STAGE:
*
ARE BOWEL MOVEMENTS REGULAR?
*
Yes
No
WHAT IS USUAL TIME?
*
Hour Minutes
AM
PM
AM/PM Option
WORD USED FOR “BOWEL MOVEMENT
*
WORD USED FOR URINATION
*
PARENT / AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S HEALTH
*
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
*
Yes
No
NAME OF DOCTOR
*
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
Yes
No
WHAT KIND AND ANY SIDE EFFECTS:
*
Type NONE if there are no side effects.
DOES CHILD USE ANY SPECIAL DEVICE(S):
Yes
No
WHAT KIND
*
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?
Yes
No
WHAT KIND
*
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PARENT/ AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S PERSONALITY
*
HOW DOES CHILD GET ALONG WITH PARENT / AUTHORIZED REPRESENTATIVE, BROTHERS, SISTERS AND OTHER CHILDREN?
*
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
*
Please Select
Yes
No
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? EXPLAIN
*
Type NONE if there aren't any.
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
*
Type NONE if there aren't any.
REASON FOR REQUESTING DAY CARE PLACEMENT
*
DATE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / Guardian Signature
*
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