Developmental History

The Commonwealth of Massachusetts

Department of Early Education and Care
Developmental History and Background Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Developmental History
Age began:
sitting*
crawling*
walking*
talking*
Does your child:

pull upcrawlwalk with support
Any speech difficulty?*
Special words to describe needs?
language spoken at home:*
any history of colic? *
Does your child use a pacifier or suck thumb? When?*
Does your child have a fussy time? When?*
How do you handle this time?
Health
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:*
Eating Habits
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?
Does your child eat with:*

spoonforkhandsOther
Toilet Habits
Are disposable or cloth diapers used?*
Is there a frequent occurrence of diaper rash?*
Do you use:

oilpowderlotionOther
Are bowel movements regular? How many per day?*
Is there a problem with...

diarrheaconstipation
Has toilet training been attempted?*
Please describe any procedure to be used for your child at Woodside:
What is used at home:*

pottychairspecial child seatregular 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:*

cribbed
Does your child become tired or 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 immedately to discuss the best sleeping position for your baby. Please also take the time to discuss your child's sleeping position with your caregiver.
When does your child go to bed at night? and get up in the morning?*
Describe any special characteristics or needs (stuffed animal, story, mood non waking etc)
Social Relationships
How would you describe your child?*
Previous experience with other children/daycare*
Reaction to strangers? *
Able to play alone?*
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?*
What would you like your child to gain from this experience at Woodside Montessori Academy?*
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?
Signature*

Clear
Date

MonthDayYear
Date
Your child's Developmental History must be updated annually. Please keep a copy for your records to refer back to for updates. Thank you.
Should be Empty:

The Commonwealth of Massachusetts

Developmental History and Background Information

Developmental History

Health

Eating Habits

Toilet Habits

Sleeping Habits:

Social Relationships

Daily Schedule