Child’s Preadmission Health History – Parent’s Report

Child’s Name *

Sex

Female

Male

Birth Date *

Father’s/Father’s Domestic Partner’s Name

Does Father/Father’s Domestic Partner live in home with child? *

Yes

No

Mother’s/Mother’s Domestic Partner’s Name

Does Mother/Mother’s Domestic Partner live in home with child?

Yes

No

Is/Has child been under regular supervision of physician?

Yes

No

Date of Last Physical/Medical Examination

Developmental History
(For infants and preschool-age children only)

Walked at

Began talking at

Toilet training started at

Past Illnesses

Specify any other serious or severe illnesses or accidents

Does child have frequent colds

Yes

No

How many in last year?

List any allergies staff should be aware of

Daily Routines
(For infants and preschool-age children only)

What time does child get up?

What time does child go to bed?

Does child sleep during the day?

Yes

No

Does child sleep well?

Yes

No

Diet Pattern

Breakfast

Lunch

Dinner

What are usual eating hours? (Breakfast)

What are usual eating hours? (Lunch)

What are usual eating hours? (Dinner)

Any food dislikes?

Any eating problems?

Is child toilet trained?

Yes

No

If yes, at what stage

Word used for “bowel movement”

Are bowel movements regular?

Yes

No

Word used for urination

What is usual time?

Health Evaluation

Is child presently under a doctor’s care?

Yes

No

If yes, name of doctor

Does child take prescribed medication(s)?

Yes

No

If yes, what kind and any side effects

Does child use any special device(s)?

Yes

No

If yes, what kind

Does child use any special device(s) at home?

Yes

No

If yes, what kind

Parent’s Evaluation of Child’s Personality

How does child get along with parents, brothers, sisters, and other children?

Has the child had group play experiences?

Yes

No

Does the child have any special problems/ fears/ needs? (Explain):

What is the plan for care when the child is ill?

Reason for Requesting Day Care Placement

I confirm that the information provided is accurate and complete.

Current Date

Health History *

Tags *

PREADMISSION HEALTH INSIGHTS

Child’s Preadmission Health History – Parent’s Report​

Developmental History(For infants and preschool-age children only)

Past Illnesses​

Daily Routines(For infants and preschool-age children only)

Diet Pattern​