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Child Profile Form
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Child Profile



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?






Parent Signature: _________________________________





Date: ______________________________________________

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