Confidential Developmental History
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent's Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Basic Information
Height
*
Weight
*
Hair Color
*
Eye Color
*
Identifying Marks
*
Primary Language of Child
*
Primary Language of Parents
*
Birth and Infancy
City & State of Birth
*
Place of Birth
*
Home
Hospital
Name of Hospital
*
Type of Birth
*
Birth Weight
*
Birth Length
*
Type of Feed
*
Breast
Bottle
Until When
*
What age did your child begin to Sit?
*
What age did your child begin to Crawl?
*
What age did your child begin to Walk?
*
What age did your child begin to Talk?
*
Any speech difficulties?
*
Is there any information about your child’s birth/infancy which you think would help the teacher more fully understand your child, for example, birth complications, illnesses, adoption?
*
Eating Habit
Special characteristics or difficulties, including allergies or sensitivities:
*
Eating Speed
*
Slow
Fast
Favorite Foods
*
Food Refuses
*
Toilet Habit
Is your child ever reluctant to use the bathroom?
*
Does your child have accidents?
*
Does your child have any special needs in this area?
*
Sleeping Habit
Does your child become tired or nap?
*
Does your child have accidents?
*
When does your child go to bed?
*
Rise
*
Dreams
*
Nightmares
*
Bed Wetting
*
Uninterrupted sleep
*
Child sleeps in
*
Own room
Shared room with sibling/s
Family bed
Family / Home
Please list household members
Name 1
*
Age
*
Relationship
*
Name 2
*
Age
*
Relationship
*
Name 3
*
Age
*
Relationship
*
How do you discipline your child?
*
Please describe your child’s schedule on a typical day
*
Do parents share responsibility for child’s daily rhythm?
*
For child’s discipline?
*
Have there been significant changes in family (death, illness, divorce/separation, moves, etc.)
*
Briefly describe your attention to family traditions, rituals and celebrations
*
Social Relationships
If your child has had previous schooling?
*
Yes
No
Name of School
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates Attended
*
What kind of experience was this for your child?
*
Has your child received a specialized evaluation, such as educational / psychological, hearing, speech,etc.?
*
Yes
No
Please describe
*
Has your child received any Academic Intervention Service (AIS) or tutoring?
*
Yes
No
Please describe
*
Does your child have an Individualized Education Plan (IEP)?
*
How would you describe your child?
*
How is your child in a social setting with peers?
*
Your child’s reaction to strangers
*
Ability to play alone
*
Favorite toys and activities
*
Fears
*
Describe the role that media plays in your child’s life
*
Hours of media exposure (TV, computer, video, electronic games, radio) daily
*
How are you hoping school will affect your child?
*
Is there anything else you would like us to know about your child?
*
Is your child up-to-date in their immunizations?
*
Yes
No
Not Sure
Comments
Parent / Guardian 1 Signature
*
Parent / Guardian 2 Signature
*
Submitter's Email
*
example@example.com
Submit
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