DEVELOPMENTAL HISTORY REPORT
Families: Here at the Fishback Center for Early Childhood Education, our program strives to get to know
children and families by using a variety of formal and informal (including conversations) to become acquainted
with and learn from families about your family structure; your preferred child-rearing practices; and information
you wish to share about your socioeconomic, linguistic, racial, religious, and cultural backgrounds. We also
want to gain information about the ways our families define their own race, religion, home language, culture,
and family structure. Program staff actively use this information about families to adapt the program
environment, curriculum, and teaching methods. We want teachers and families to work together to help
children participate successfully in the early childhood setting when professional values and practices differ
from your family values and practices. Therefore, please fill in the blanks as completely as possible. This
information is to help our staff better understand your child and to help you know what to expect from the
SDSU Preschool Laboratory Program. Your child’s care during the day is a responsibility we share.
Current Date:
Child’s Full Name:
Birth Date:
Address:
Home Number:
Parent/Guardian 1:
Relation to Child:
How would you like to be addressed in person? (ex. Mr., Mrs., Dr., by first name, etc.):
How would you like to be addressed in writing? ex. Mr., Mrs., Dr., by first name, etc.):
Parent/Guardian 2:
Relation to Child:
How would you like to be addressed in person? (ex. Mr., Mrs., Dr., by first name, etc.):
How would you like to be addressed in writing? ex. Mr., Mrs., Dr., by first name, etc.):
Child lives with:
Parent/Guardian 1 Employer:
Address:
Work Number:
Work Hours and Work Days:
Parent/Guardian 2 Employer:
Address:
Work Hours and Work Days:
Work Number:
Stepparent(s) Name(s):
Employer:
Ph. Number:
Address:
Child’s Home and Family
Grandparents’ Names/Addresses:
Other Children residing within the child’s home and their ages:
Name
Age
Any Special Needs
What nationalities are included in your immediate family?
Please list all of your child’s cultural backgrounds?
What is the dominate language of the home?
Additional language(s) spoken to the child:
If you would prefer that our program policies, operating procedures, and parent permission forms be given to
you in another language besides English, please indicate the other language here and let your Mentor Teacher
know:
What other information would you like to share with us about your family’s background?
Now living in: (please check)
House
Apt.
Town
List other child care arrangements (be specific):
Trailer
Country
Other
Please list any concerns due to your religion preference that would affect your child’s participation in school
activities (ex. Holidays):
Does your child attend other regularly scheduled programs (gymnastics, dance, music, etc.)? If so, what
programs?
Describe your child’s personality:
What methods of child guidance have you used most often and find most useful?
Has your child been separated from one or both parents for any length of time? Specify length of time and
reaction to separation:
What is the child’s general reaction to separation?
Is either parent required to be away from home for considerable amounts of time? Explain:
Have there been any changes in the family since the birth of this child due to births, deaths, adoptions, divorce,
remarriage, parent’s separation, health, moving, somebody coming to live with the family or major changes? If
so, specify and explain child’s reaction to the change:
How does your child interact with adults? (Be specific):
How does your child interact with other children? (Be specific):
Name the things of which your child is afraid and how is the fear handled?
What does your child use as security?
Special Interests/Hobbies:
Father:
Mother:
Child:
Other Family Member(s):
List child’s favorite toys, play activities, books, family pets, etc.:
Does your child have an imaginary playmate? Describe:
Name the people your child talks about often and their relationship to the child:
Health History
Does your child have any significant health concerns? If so, please describe:
Does your child have any special needs? If so, please describe:
Does your child have any allergies? If so, please describe, in detail, the item and the reaction:
List medications taken on a regular basis (if any):
Are there any side effects?
Yes
No Please describe:
Comment on health of other member of child’s immediate family:
Food and Eating Experiences
Child’s favorite foods:
Disliked foods:
Describe child’s attitude and behavior at mealtime:
What is your response to your child’s attitude or behavior?
Potty Training Experiences
At what age was your child trained for urination/bowel movements?
Describe difficulty (if any) with toilet training:
Sleeping and Nap Experiences
Is there anything in your child’s sleeping habits which could interfere with his/her school attendance?
Other remarks about naps or night sleep:
Sexuality
What label(s) has your child attached to various part of his/her body?
Has he/she asked you where babies come from?
Yes
No
How did you respond to the situation?
Do you have any concerns about your child’s knowledge of sexuality and/or reproduction?
Birth and Early Experiences
Describe condition and important factors during pregnancy and delivery, such as premature, low birth weight,
etc.:
Is child adopted?
Yes
No
If yes, does the child know it?
Yes
Age of adoption:
Comment on the health of the infant during the first year:
Is there anything else you would like us to know about your child?
Signed
(Parent or legal guardian)
Date:
No