Child's Pre-admission Health History

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CHILD’S NAME(Required)

First Name Last Name

GENDER(Required)

BIRTHDATE(Required)

Month

Day

Year

Email(Required)

Entering your email address will send you a copy of this form fill out.

PARENT / AUTHORIZED REPRESENTATIVE NAME(Required)

First Name Last Name

DOES PARENT / AUTHORIZED REPRESENTATIVE LIVE IN HOME WITH CHILD?(Required)

Yes

Do you need to add an additional Parent / Authorized Representative living in home with child?(Required)

Yes

IS / HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?(Required)

Yes

DATE OF LAST PHYSICAL/ MEDICAL EXAMINATION(Required)

Month

Day

Year

DEVELOPMENTAL HISTORY

For infants and preschool-age children only

WALKED AT(Required)

BEGAN TALKING AT(Required)

TOILET TRAINING STARTED AT(Required)

PAST ILLNESSES

Check illnesses that child has had and specify approximate dates of illnesses:

Chicken Pox

Dates

Month

Day

Year

Asthma

Dates

Month

Day

Year

Rheumatic Fever

Dates

Month

Day

Year

Hay Fever

Dates

Month

Day

Year

Diabetes

Dates

Month

Day

Year

Epilepsy

Dates

Month

Day

Year

Whooping Cough

Dates

Month

Day

Year

Mumps

Dates

Month

Day

Year

Poliomyelitis

Dates

Month

Day

Year

Ten-Day Measles (Rubeola)

Dates

Month

Day

Year

Three-Day Measles (Rubella)

Dates

Month

Day

Year

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS(Required)

Type NONE if there not any serious / severe illnesses / accidents.

DOES CHILD HAVE FREQUENT COLDS?(Required)

Yes

HOW MANY IN LAST YEAR?(Required)

LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF(Required)

Type NONE if there are no allergies staff should be aware of.

DAILY ROUTINES

For infants and preschool-age children only

WHAT TIME DOES CHILD GET UP?(Required)

Hours

Minutes

AM/PM

WHAT TIME DOES CHILD GO TO BED?(Required)

Hours

Minutes

AM/PM

DOES CHILD SLEEP WELL?(Required)

Yes

DOES CHILD SLEEP DURING THE DAY?(Required)

Yes

WHEN?(Required)

HOW LONG?(Required)

DIET PATTERN:

BREAKFAST

What does child usually eat for these meals?(Required)

What are the usual eating hours(Required)

LUNCH

What does child usually eat for these meals?(Required)

What are the usual eating hours(Required)

DINNER

What does child usually eat for these meals?(Required)

What are the usual eating hours(Required)

ANY FOOD DISLIKES?(Required)

Type NONE if there is no food dislikes.

ANY EATING PROBLEMS?(Required)

Type NONE if there is no food dislikes.

IS CHILD TOILET TRAINED?(Required)

Yes

AT WHAT STAGE:(Required)

ARE BOWEL MOVEMENTS REGULAR?(Required)

Yes

WHAT IS USUAL TIME?

Hours

Minutes

AM/PM

WORD USED FOR “BOWEL MOVEMENT(Required)

WORD USED FOR URINATION(Required)

PARENT / AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S HEALTH(Required)

IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?(Required)

Yes

NAME OF DOCTOR(Required)

DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

Yes

WHAT KIND AND ANY SIDE EFFECTS(Required)

Type NONE if there are no side effects.

DOES CHILD USE ANY SPECIAL DEVICE(S):

Yes

WHAT KIND(Required)

DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

Yes

WHAT KIND(Required)

PARENT/ AUTHORIZED REPRESENTATIVE EVALUATION OF CHILD’S PERSONALITY(Required)

HOW DOES CHILD GET ALONG WITH PARENT / AUTHORIZED REPRESENTATIVE, BROTHERS, SISTERS AND OTHER CHILDREN?(Required)

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?(Required)

Yes

DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? EXPLAIN(Required)

Type NONE if there aren't any.

WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?(Required)

Type NONE if there aren't any.

REASON FOR REQUESTING CHILD CARE PLACEMENT(Required)

DATE(Required)

Month

Day

Year

Parent / Guardian Signature(Required)

CAPTCHA

Child’s Pre-admission Health History

DEVELOPMENTAL HISTORY

PAST ILLNESSES

DAILY ROUTINES

DIET PATTERN:

BREAKFAST

LUNCH

DINNER

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