Infant Developmental History - Close to My Heart
Child's Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Parents' Names *
Your answer
What language is spoken in your home? *
Your answer
Sleeping - Fill in typical sleeping patterns.
Nighttime: From _______ to __________ *
Your answer
A.M. Nap: From ______ to _________
Your answer
P.M. Nap: From ______ to _________
Your answer
Preferred sleeping position: *
Feeding:
Baby drinks:
If formula or other - what type?
Your answer
Baby uses: *
Required
Baby prefers bottles: *
Baby is fed every _______ hours. *
Your answer
Baby's typical feeding times and amounts (include foods and liquids)
Breakfast *
Your answer
Lunch *
Your answer
Snacks *
Your answer
Check snack/breakfast items that we may serve your child at the center: *
Required
Other foods your baby enjoys:
Your answer
Allergies: *
Required
If you checked any allergies, please explain.
Your answer
Health
Is your baby generally healthy? *
Describe any health concerns.
Your answer
List any on-going medications your child is taking. (Write NONE, if there are no medications.) *
Your answer
My child has _____ ear infections in a typical year. *
Are you concerned with your child's hearing? *
My child has _____ colds/sore throats with a fever in a typical year. *
Are you concerned about your child's eyes or vision? *
Has your child been seen by a medical specialist? *
If yes, for what?
Your answer
Does your child have any disabilities? *
Does your child have any other illnesses/diseases? *
Has your child been hospitalized within the past year? *
Has your child had any serious accidents or poisonings? *
Does your child chew unusual things such as pencils, chalk, crib, window ledges, paint chips plaster, or hair? *
Check anything your child has had:
Diapering
How frequent are bowel movements? *
Your answer
Describe normal appearance of bowel movements. *
Your answer
Is your baby prone to diaper rashes? *
If yes, tell us the best treatment to use.
Your answer
Getting Acquainted
Share with us the best ways to comfort your child: *
Your answer
List favorite toys and activities: *
Your answer
Does your baby use a pacifier? *
Describe any other information which would be helpful for us to know about your baby.
Your answer
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