The Commonwealth of Massachusetts Department of Early Education and Care
SG/LG/SADevelopmentalHistory20100122
Casa Esme Developmental History Form
EEC Regulations for licensed child care facilities require this information to be on file to help us best
address the needs of children while in care.
Child's Name: _______________________________ Date of Birth: _______________________
Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY
Age began sitting: _________ crawling: ___________ walking: ___________ talking: ____________
*Does your child pull up? __________*Crawl? _____________ *Walk with support? ______________
Any speech difficulties? ___________________________________________________________
Special words used to describe needs __________________________________________________
*Any history of colic? _____________________________________________________________
*Does your child use pacifier or suck thumb? ___________ *When? ___________________________
*Does your child have a fussy time? _____________ *When?________________________________
*How do you handle this time?_______________________________________________________
___________________________________________________________________________________
HEALTH & DEVELOPMENT
Any known complications at birth? _________________________________________________________
Serious illnesses and/or hospitalizations:________________________________________________
Special physical conditions, disabilities:_________________________________________________
Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: ____________________________
____________________________________________________________________________
Regular medications: _____________________________________________________________
Do you know the Dept. of Early Education and Care’s Child sick policies that Casa Esme follows?
(
) Yes (
) No
Is this your first, second, third, etc child? ___________ How do you get answers to health and child
development questions (pediatrician, family member, internet, friend)? ___________________________
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Would you like information on child development from Casa Esme? ____Yes
____No; If yes, what topics
would you like information on?______________________________________________________
EATING HABITS
Is child a good eater, a picky eater? ___________________________________________________
Special characteristics or difficulties: __________________________________________________
*If infant is on a special formula, describe its preparation in detail: ______________________________
____________________________________________________________________________
Favorite foods: _________________________________________________________________
Foods refused: _________________________________________________________________
* Is your child fed held in lap?____________ High chair?__________ Other? ___________________
* Does your child eat with spoon?____________ Fork?____________ Hands?___________________
TOILET HABITS
*Are disposable or cloth diapers used? ___________*Is there a frequent occurrence of diaper rash?______
*Do you use: oil:_______ powder:_______ lotion:_______ other:____________________________
*Are bowel movements regular?______________________ How many per day?__________________
*Is there a problem with diarrhea?_____________________ Constipation? _____________________
*Has toilet training been attempted?___________________________________________________
*Please describe any particular procedure to be used for your child at the center: ____________________
____________________________________________________________________________
*What is used at home? Potty chair? _________ Special child seat? __________ Regular seat? ________
*How does your child indicate bathroom needs (include special words): __________________________
Is your child ever reluctant to use the bathroom? __________________________________________
Does your child have accidents? __________________________________________________________
SLEEPING HABITS
*Does your child sleep in a crib? _________ Their Own Bed? __________ In Parents room?__________
Does your child become nap during the day (include when and how long)? __________________________
__________________________________________________________________________________
Please note: The American Academy of Pediatrics has determined that placing a baby on his/her
back to sleep reduces the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden and
unexplained death of a baby under one year of age. If your child does not usually sleep on his/her
back, please contact your pediatrician immediately to discuss the best sleeping position for your
baby. Please also take the time to discuss your child’s sleeping position with your caregiver.
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What time does your child go to bed at night? __________ and get up in the morning? _______________
Does your child cry before napping? ____________ If so, for how long usually?____________________
If so, How are they comforted? ______________________________________________________
Describe any special characteristics or needs (stuffed animal, story, mood on waking etc) _______________
___________________________________________________________________________________
READING HABITS
How frequently does someone read to your child? ______________? Reading duration:______________
Who reads to the child?_________________ At bedtime? __________ At awake times: ____________
Can child hold a book and turn pages? _________ Does child look at books by her/himself? ____________
Favorite book / author____________________________________________________________
Favorite types of books? (animals, family stories, etc) _______________________________________
SOCIAL RELATIONSHIPS
How would you describe your child?
____________________________________________________________________________
____________________________________________________________________________
Has your child been in any child care before? ( )Yes ( ) No. How was their experience:______________
____________________________________________________________________________
Reaction to new people:___________________________________________________________
Able to play alone_____________________ For how long _________________________________
Favorite toys and activities: _________________________________________________________
Fears (the dark, animals, etc.):_______________________________________________________
How do you comfort your child?______________________________________________________
What is the method of behavior management/discipline at home?
____________________________________________________________________________
____________________________________________________________________________
DAILY SCHEDULE
Please describe your child’s schedule on a typical day. For infants, please include awakening, eating,
time out of crib/bed, napping, toilet habits, fussy time, night bedtime, etc.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is there anything else we should know about your child? _____________________________________
___________________________________________________________________________________
___________________________________________________________________________________
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PLAY:
What are your child's favorite toys:____________________________________________________
What are your child's favorite activities: ________________________________________________
What are child's favorite family activities________________________________________________
Thank you for filling this out!
_______________________________
(Print Parent/Guardian Name)
__________________________ Date: _______
(Parent/Guardian Signature)
Casa Esme Child Development Form
________________________________
(Print Parent/Guardian Name)
_____________________Date:_________
(Parent/Guardian Signature)
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