Early Childhood Center
Child’s Personal History — Toddler Classroom
In order to help us know and understand your child more completely, please fill out this personal history form.
FAMILY INFORMATION
Child’s full name: ____________________________________________________________________________________________
Last
First
Any nickname: ___________________________________________
Name:
Middle
Date of birth: _______________________________
Parent/Guardian
Parent/Guardian
______________________________________________
_______________________________________________
Occupation: ______________________________________________
_______________________________________________
Employer:
_______________________________________________
______________________________________________
Are there any family factors we should know about? (i.e. separation, divorce, a recent move, a death, a birth, a serious illness, etc.)
Please tell us about the people who live in the home with your child (grandparents, siblings and their ages).
Doe your family have pets? ___Yes ___ No If yes, please describe.
Would you like to share any cultural or religious practices that are important to your family?
HEALTH HISTORY
Was your child ___ full term ___ premature?
Please describe any complications during pregnancy, labor, and/or delivery.
Is your child adopted? ___Yes ___ No
If yes, at what age? _______
Does your child have any health problems that we should be aware of?
Does your child have any allergies or sensitivities? ____Yes ____No If yes, please describe.
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ECEC-14-16328(6/14)
Child’s Personal History (continued)
Does your child take any medication on a regular basis? ____Yes ____No If yes, please describe.
Does your child have a disability that has been diagnosed? ____Yes ____No If yes, please describe.
Do you have any concerns about your child’s current health or development?
FEEDING
What is your child’s typical eating pattern at home?
Are there any food restrictions?
What are his or her food likes and dislikes?
Does your child feed him or herself? ____Yes ____No ____ With fingers ____ With utensils
Does your child drink from a cup? ____Yes ____No ____ With a lid ____ Without a lid
Do you have any feeding/mealtime concerns or rituals that you want to tell us about?
SLEEPING AND NAPPING
What are you child’s regular sleeping patterns?
Wakes at ______ Naps at _______
_______ ________ Goes to bed at _______
What do you want us to know about how you put your child to sleep?
Does your child have a favorite toy or item he/she uses for comfort?
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Child’s Personal History (continued)
What frightens your child? (loud noises, strangers, animals, etc.)
How do you comfort your child?
DIAPERING AND TOILETING
What type of diapers, wipes and ointment (if any) will you be bringing for us to use at the Center?
What is your child’s regular bladder and bowel pattern?
Please describe your child’s current interest in using the toilet/potty seat at home (if any)?
What words do you use for body parts or toileting needs?
HOME LANGUAGE
What languages are spoken in your home? _____________________________________________________________________
If your home language is not spoken in the program, would you be willing to teach us some key words in your language?
____Yes ____No
Does your child have any problems making sounds? ____Yes ____No
• List sounds your child makes that approximate words.
• First words
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Child’s Personal History (continued)
PERSONALITY AND INTERESTS
What type of activities does your child enjoy the most?
Has your child had experience using playground equipment? ____Yes ____No If yes, what types?
How does your child express his or her likes and dislikes?
Please describe your child’s experiences with non-parental care (family members, home child care and group childcare).
• How does your child separate from you?
• How does your child relate to other children and unfamiliar adults?
What do you hope your child will gain from his or her experience with us?
Printed name of Parent/Guardian(s) ___________________________________________________________________________
Signature of Parent/Guardian(s) ______________________________________________________________________________
Date: _________________________________________
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