F.A.L.L.S. Cooperative Preschool
Individual Health, Educational, and Family Information
Child’s Name: ____________________________ Sex: ☐ M ☐ F Birthdate: ______________.
Date completed: __________________
Please complete the following information in order to help us best support your child and family. If
additional space is needed, please use back or add additional pages. If you are uncomfortable
providing any information, please leave those items blank.
Child’s Health History
Name of Doctor ____________________
City/State _________________
Phone number ____________
Were there any significant problems during pregnancy or birth? ☐ Yes ☐ No
If yes, please explain: _______________________________________________________________.
Has your child had surgery or been hospitalized? ☐ Yes ☐ No
If yes, please explain, include date: _____________________________________________________
Does your child take medication on a regular basis? ☐ Yes ☐ No
If yes, list medication(s), dosage, and reason: _____________________________________________.
Check if your child has had any of the following:
☐ Asthma
☐ Bladder/urinary tract problems ☐ Frequent ear infections
☐ Other breathing problems
☐ Bowel/GI problems
☐ Other ear/nose/throat problems
☐ Seizures
☐ Bone/joint problems
☐ Diabetes/endocrine problems
☐ Heart/cardiovascular problems
☐ Eczema/skin problems
☐ Injury or abuse
☐ Tuberculosis exposure
☐ Other _________________________________________________
If you marked any of the above, please describe:
________________________________________________________________________________________
________________________________________________________________________________________
Child’s Nutrition History
Does your child have any problems with chewing or swallowing? ☐ Yes ☐ No
If yes, please explain: _______________________________________________________________.
Do you have concerns about your child’s: ☐ Eating habits ☐ Height ☐ Weight
If yes, please explain: _______________________________________________________________.
Does your child have any allergies or reactions (including intolerances) to food, medication, insects, animals,
or other substances? ☐ Yes ☐ No
If yes, please list each food or substance separately and describe reaction, including severity:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does your child require epinephrine (epi-pen) in case of exposure? ☐ Yes ☐ No ☐ N/A
Is there any food or drink that your child should not eat for cultural, religious, personal, or medical reasons
(other than allergy)? ☐ Yes ☐ No
If yes, please explain: _______________________________________________________________.
__________________________________________________________________________________
.
Child’s Experiences/Independence Skills
Please remember that our school includes toddlers up to children getting ready to enter kindergarten. Not all
skills are expected at every level.
Can your child:
Use the restroom independently? ☐ Yes ☐ No
Wash and dry his/her hands independently? ☐ Yes ☐ No
Remove his/her coat independently? ☐ Yes ☐ No
Put on his/her coat independently? ☐ Yes ☐ No
Ask an adult for help? ☐ Yes ☐ No
Be comfortable talking to an unfamiliar adult at school? ☐ Yes ☐ No
Sit and listen to a short story? ☐ Yes ☐ No
Has your child attended preschool or daycare before? ☐ Yes ☐ No
Has your child attended story time at the library? ☐ Yes ☐ No
Has your child participated in other group activities with other children the same age? ☐ Yes ☐ No
Has your child experienced difficulty with any of these situations? ☐ Yes ☐ No
What helps your child calm down if he/she is upset?
_______________________________________________________________________________________
Parental Concerns
Do you have concerns about your child’s:
☐ Vision ☐ Hearing ☐ Speech ☐ Behavior ☐ Social Skills ☐ Motor skills ☐ Learning ☐ Other
If you have concerns, please describe:
________________________________________________________________________________________
________________________________________________________________________________________
.
Family Information
At F.A.L.L.S., we have a wonderful group of families that come from many different walks of life, countries,
cultures, beliefs, and religions. It is important to us that each child and his/her family are represented at our
preschool.
Who lives in your home? Please include their names, relationships, and ages of siblings/other children.
________________________________________________________________________________________
________________________________________________________________________________________
Do you speak a language other than English in your home? ☐ Yes ☐ No
If yes, which language(s): ___________________________________________________________
Would you be willing to translate for other families, if needed? ☐ Yes ☐ No
Are there any special traditions or holidays that you would like to share with our school? ☐ Yes ☐ No
If yes, please describe: _____________________________________________________________.
Are there any holidays you wish your child NOT to learn about in school? (Our school does not teach the
religious aspects of any holiday.)
☐ Yes ☐ No
If yes, please describe: _____________________________________________________________.
Is there anything you would like to share with us about your family? ☐ Yes ☐ No
If yes, please describe: _____________________________________________________________.
Our school is run entirely by our families. Do you or anyone in your immediate family have any special skills or
knowledge that you would be willing to share with the preschool? Examples could include trade skills
(carpentry, repair, graphic design, accounting, etc), talents, or access to resources. ☐ Yes ☐ No
If yes, please describe: _____________________________________________________________.