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Child's Full Name: __________________________________
Child's Birth Date: __________________________________
Home Address: ______________________________________
Parent's Names: _____________________________________
Child's Physician Name: ______________________________
Health Card #: ______________________________________
Has or does your child have any known health problems? Yes ( ) No ( ). If yes, describe:
Does your child have any known allergies? Yes ( ) No ( ).
If yes, please list:
Special instructions in the event of an allergic reaction:
List communicable diseases your child has had (ex. chicken pox, measles, and mumps)
Are your child's immunizations up to date? Yes ( ), No ( )
Is your child prone to: (circle those that apply); stomach upsets, colds, headaches, sore throats, ear aches, other?
Are there any indications of vision or hearing problems? Yes ( ) No ( )
Has he/she had any recent serious illness? Yes ( ) No ( ).
What is your child's general health status?
Does your child have any mental or physical disabilities? Yes ( ) No ( ).
If yes, please explain:
Do you have a back up plan if your child is ill and cannot attend day care?
Yes ( ) No ( ).
What is your child's eating habits? (Times child usually eats, mind trying new things, etc.)
If your child is drinking formula, do they prefer it cold or warm? _________________
Child's usual dining habits (circle those applicable); High chair, table, uses utensils, bottle, sipper cup, regular cups.
Does your child have a small or large appetite?
What are your child's favorite foods?
What does your child strongly dislike?
How would you describe your child's personality?
Does your child have a regular bedtime schedule? Yes ( ) No ( ).
Does your child have any sleep problems? Yes ( ) No ( ). If yes, describe.
If infant, how do you prefer to be placed in the crib (front, back, side). Please circle one.
What time does your child usually go to bed/afternoon nap?
What time do they wake in the morning?
What is their disposition when waking up? i.e, happy, grouchy, clings, slow?
Please list your child's favorite activities:
Please list your Child's favorite toys:
Special instructions concerning care, medications or diet not mentioned?
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