Family and Social History

Child’s Name ______________________________ Date of Birth __________________

Mother (Guardian) _______________________________________________________

Father (Guardian) _______________________________________________________

Marital Status of Parents:

Married ________ Divorced ________ Separated _______ Single Parent _________

Custody/Visiting Arrangements _____________________________________________

Brothers and Sisters of Child:

Name __________________________________ Birth Date ________________

Name __________________________________ Birth Date ________________

Name __________________________________ Birth Date ________________

Other Members of Household:

Name __________________________________ Age _______

Name __________________________________ Age _______

Napping

Does your child take naps? ______________(From __________TO__________)

Does your child have a special toy or blanket to sleep with? _______________________

Social Relationships

Do you feel your child will adjust easily to the Daycare? _________________________

What makes your child angry or upset? ______________________________________

How does your child show his or her feelings? _______________________________

Is your child frightened by such things as: animals, rough children, loud noises, the dark, or storms? __________________________________________________________

Favorite toys and activities at home: _________________________________________

Does your child like to be read to? ______________ Listen to music? _____________

Eating

Is your child usually hungry at meal times? ___________ Between meals?___________

What are some of your child’s favorite foods? __________________________________

Least Favorite? ___________________________________________

Does you child eat with a spoon? ______________ Hands? ____________________

Are there any dietary restrictions we should know about? ________________________

Toilet Habits

Does your child indicate his toilet wishes? ____________________________________

Does your child need help with toileting ? _____________________________________

Does your child have accidents? ___________ 

How does your child react?____________________________________