CAMPBELL CHILD & FAMILY CENTER
PERSONAL HISTORY Please give any information concerning your child; this form is kept in your child’s file and held in strict confidentiality.
CHILD’S NAME
/
NICKNAME
FAMILY: CHILD’S SIBLINGS
How many brothers/sisters, if any:
/
YOUR CHILD’S FIRST DAY OF SCHOOL
Adopted? NO YES, AGE:
Is child aware of being adopted? NO
1. SIBLING NAME, AGE
.
YES
3. SIBLING NAME, AGE
2. SIBLING NAME, AGE
4. SIBLING NAME, AGE
Please list any other people that are living with your child and their relationship to your child:
Describe any other child care arrangements your child has experienced prior to Campbell Center:
DEVELOPMENTAL: CHILD’S BIRTH WEIGHT:
Unusual circumstances at delivery?
FULL-TERM
PREMATURE
WEEKS AT DELIVERY:
C-SECTION
.
ANOXIA (cord around baby’s neck)
Physical difficulties in early life?
Age when child learned to CRAWL:
YES NO Does child dress self?
YES NO Undress self?
SAT ALONE:
WALK:
.
Does child show preference for: RIGHT-HAND LEFT-HAND
NO-PREFERENCE
Are there any special needs/considerations the staff should make for your child due to his/her physical condition?
LANGUAGE: What was your child’s first language?
What languages does your child speak fluently?
What languages do you use to communicate with your child at home?
Does child have any speech difficulties? YES
NO
APPROXIMATE AGE WHEN YOUR CHILD:
Named simple objects:
Repeated short sentences:
CHILD’S PRESENT LEVEL OF LANGUAGE DEVELOPMENTS
Two/three word sentences:
Simple sentences/phrases:
Complex sentences (explanatory, descriptive, etc.):
Sample of child’s speech:
.
EATING: Is child vegetarian? YES (explain below)
NO
Child’s appetite is generally: EXCELLENT
POOR
GOOD
What time does your child usually eat: BREAKFAST
LUNCH
DINNER
.
What type of milk does your child drink?
List child’s favorite foods:
List foods child dislikes:
FOOD ALLERGIES – Other dietary restrictions (Special Dietary Statement must be on file; please request this form at Campbell Center)
SLEEPING: How often does your child take naps/rest?
DAILY
ONLY DURING THE WEEK
OCCASSIONALLY
At approximately what time?
For how long?
.
NOTE: the center must provide a rest period for all preschool-age children remaining in the center longer than 4 hours.
Age child slept through the night:
Does child sleep well? YES
NO
Approximate time child goes to bed:
Arises:
.
Child’s attitude toward bedtime:
Describe special bedtime routine:
TOILETING HABITS: AGE WHEN ESTABLISHED: BLADDER training
BOWEL training
Daytime:
.
Nighttime:
.
CHILD’S REACTION – What words does your child use to indicate URINATION?
What words does child use to indicate BOWEL MOVEMENT?
Are bowel movements regular? YES
NO
If they occur during the day, usually what time?
What responsibility does child assume toward toileting?
PLAY: Has child had previous group or preschool experience? YES
If YES, When and where?
How does your child respond to new situations?
NO
Separation concerns we should be aware of?
Does child have neighborhood playmates? Specify:
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Does child prefer to play ALONE?
Does child prefer to play WITH OTHER CHILDREN?
Does child prefer to play WITH ADULTS?
Is child dependent upon adult direction and suggestion in his/her play?
Any difficulties in play?
.
PLAY: LIST FAVORITE TOYS & ACTIVITIES
Indoor
.
Outdoor
How often does your child watch television? DAILY
If so, when & where:
What type of activities does child enjoy sharing with
family members?
3-5 TIMES PER WEEK
.
LESS THAN 2 TIMES WEEKLY
How frequently are activities shared with…
Mother: DAILY WEEKLY SPECIAL OCCASIONS
Father: DAILY WEEKLY SPECIAL OCCASIONS
Siblings: DAILY WEEKLY SPECIAL OCCASIONS
Whole family: DAILY WEEKLY SPECIAL OCCASIONS
GENERAL: What are your child’s strengths/skill mastery?
What aspects of your child do you find MOST enjoyable?
What aspects of your child do you LEAST enjoy?
How does your child express happiness/enjoyment?
How does your child express anger, frustration, disappointment, etc.?
How does your child show fatigue?
How would you describe your child’s personality?
Does your child have any fears? How shown?
PEOPLE
.
NOISES
.
ANIMALS
.
OTHER
Comforting techniques that work best for my child:
.
DIVORCED PARENTS
Is MOTHER remarried?
Is FATHER remarried?
STEPFATHER’s name:
NO
YES, last name:
.
NO
YES, STEPMOTHER’s name:
.
Explain custody and/or visitation arrangements:
_________________________________________________________________________________________________
PARENT/GUARDIAN SIGNATURE
2nd PARENT/GUARDIAN SIGNATURE
DATE