HRG-UCLCC - Family Information
Developmental History
Today’s Date ______________
Child’s Name
Birthdate
Male
Female____
Address:
Family Information
With whom has the child lived for most the past year?
Mother_____ Father _____ Both_____ Guardian_____ Other (specify)_____________________________
Other children in the family:
Name _______________ Age _____ Name ________________ Age _____ Name ________________ Age _____
Other people living in the household _________________________________
_____________________________
What languages are spoken at home? ____________ Other (specify) _____________________________________
Explain any family beliefs that you feel we need to know about (NAEYC criteria) _____________________________
_______________________________________________________________________________________________
Have there been any major changes in your family during the past 6 months –1 year? (i.e. divorce, death in family,
move, etc.) ___ No
Yes Explain:
Has your child had previous childcare experiences?
____Yes ____ No
If yes, for how long? ___ 6 months ___ 1 year ___ 2 years ___ more than 2 years
Name of child’s present or most recent school? _______________________________________________
Does your child have opportunities to play with other children?
___ Yes ___ No
To the best of your knowledge does your child exhibit any of the following:
___Language problems
___Fear of new situations
___Other Fears/Anxiety
____ Learning disability
___ Physical handicaps
____ Separation from parent ___ Food Allergies
____ Vision
___ Hearing concerns
___ Speech Problems
___ Other Allergies
___ Other
Explain:
Do you have any concerns about your child’s sleeping patterns (going to bed with difficulty or waking often during the night)?
___ Yes ___ No If yes, please explain: ________________________________________________________________
__________________________________________________________________________________________________
Is your child – Highly active? ___ Yes ___ No
Very quiet?
___ Yes ___ No
Is there anything else in your child’s physical development you would like to share with the HRG-UCLCC?
(i.e. surgeries, frequent ear infections, significant injuries, anxiety, etc)
When you discipline your child at home, what do you do?
What are your child’s favorite things (people, entertainment, activities)?
__________________________________________________________________________________________________
Do you have talents, skills, etc. you would be willing to share with staff or children: Explain
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Parent Involvement – what time would be better for you to participate in center activities for families?
Mornings _________ Lunch time __________
Afternoons _________
Evenings ________________
Which events would you participate in?
Breakfast w/families ___ Potluck ___ Back to School Night ___ Other Suggestions _____________________________
Parent folder\Required Forms\Developmental History