Forms: Child History 2’s Class

Please complete the following history form and click on the submit button at the end of the form. All information is confidential. Thanks for your help!

Child's Full Name
First Last
Nickname
Birth date
MM slash DD slash YYYY
Parent's Name
First Last
Parent's Name
First Last
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Email (additional email address optional)
Home Phone
Cell Phone
Parent's Business Address and Phone Nnumber
Parent's Business Address and Phone Number
Marital Status
- Married
- Separated
- Divorced
Names and ages of other children in the family:
Other relatives or caretakers living at home:
Other caregivers
If anyone else helps you care for your child on a regular basis, please provide his/her name(s).
Is there another language spoken at home? If so, what?
Was your child adopted? If so, at what age? What has s/he been told about the adoption?
Does the family attend a church or temple? If so, which one?
HEALTH: Physician's name, address and phone number:
Is your child in good health?
Does your child get frequent colds?
Does your child get frequent ear infections?
Has your child ever been hospitalized or had any serious accidents? If so, please explain.
Does your child have any allergies? If so, to what, and what type of reaction does s/he get?
Does your child take any medication? If so, please explain.
Has your child had any reactions or recent behavioral changes?
Is your child a good eater?
Does your child sleep well? How many hours per night? Does s/he nap?
Does your child have nightmares or other sleeping problems?
Are you aware of any fear or anxieties your child has? If so, please explain.
SPECIAL OCCURRENCES: Has there been a serious illness or death in the family during your child's lifetime? If so, what was s/he told and what was his/her reaction?
PLAY AND SOCIAL EXPERIENCES: does your child play alone?
Does your child prefer:
- adults
- children
- no preference
Does s/he has other children to play with? If so, how does s/he get along with them?
Please describe your child's style of play (e.g. active, shy, demanding, bossy, aggressive, leader, follower):
Favorite toys, games and stories:
Favorite activities (outdoors, books, music, painting, building, etc.):
Does your child watch TV/videos daily? Number of hours per day? What kind of shows?
Has your child ever attended another nursery school or playgroup? If so, which one?
Please describe your child's reaction to any previous nursery or playgroup experience.
SEPARATION: How does your child react when parents leave?
With whom does your child stay when you leave him/her?
Has s/he ever been separated from his/her mother and/or father for any length of time? If so, under what circumstances?
DEVELOPMENT AND SPEECH: How old was your child when s/he sat alone?
How old was s/he when s/he walked?
How old was s/he when s/he said single words?
How old was s/he when s/he made phrases or sentences?
How does your child communicate his/her needs?
Does your child understand and follow through when being spoken to?
Has your child had any formal developmental evaluations or assessments? If yes, please explain.
Does your child currently receive any additional services for any reason? (e.g. speech, occupational therapy, physical therapy, other) If so, what are the services and frequency of therapy?
OTHER: Why do you want your child in nursery school?
Is there anything else you feel would be important for your child's teachers to know to better understand, comfort, and teach your child?

Forms: Child History 2’s Class

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