Health History Form

Allergies to be Aware
List any allergies the staff should be aware of.
Time Get Up*
What time does child get up?
Time Go to Bed*
What time does child go to bed?
Sleep Well*
Does child sleep well?
Sleep During Day*
- Yes
- No
Sleep During Day - When
Sleep During Day-How Long
Breakfast Typical*
Breakfast Time*
Lunch Typical*
Lunch Time*
Dinner Typical*
Dinner Time*
Food Dislikes*
Eating Problems
Toilet Training?
Is child toilet trained?
- Yes
- No
Toilet Trained Stage
Regular BM?
Does child have regular bowel movement?
- Yes
- No
BM Time
Word for BM*
Word for Urinate*
Evaluation of Health*
Parent/Authorized Representative evaluuation of child's health

In Doctors Care*
Is Child presently under a doctor's care?
- Yes
- No
Doctor's Name
Prescription Medications*
- Yes
- No
Prescription Detail - Side Effects
If child takes prescription medications, what kind and any side effects:
Special Devices*
- Yes
- No
Special Devices - Details
What kind of special devices?
Special Devices at Home*
- Yes
- No
Special Devices Home - Details
What kind of special devices?
Evaluation of Personality*
Parent/authorized representative evaluation of child's personality
Get Along*
How does child get along with parent/authorized representative, brothers/sisters, and other children?
Group Play Experiences*
Has the child had group play experiences?
Problems Fears Needs*
Does the child have any special problems/fears/needs? Explain.
Care When Ill*
What is the plan for care with the child is ill?

Reason for Child Care
Reason for requesting day care placement.
Parent/Guardian Signature*
Date Signed
Date Format: MM slash DD slash YYYY
Email
If you would like a copy of this signed form emailed to you, please enter an email address. Leave blank if a copy is not wanted.
Phone
This field is for validation purposes and should be left unchanged.