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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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