A Little About My Childs Temperament

"A Little About My Child's Temperament"
Areas you would like to see your child working out?
Your normal method of discipline
Any special needs or concerns
Are your child's immunizations up to date? (Please Attach a copy of immunizations) Include signature of nurse or doctor.
Are you concerned that your child may be prone to any type of allergies?

YesNo
(If yes, describe)
Does your child have any known allergies?

YesNo
(If yes describe)
Does your child have any known medical conditions in which we should know about?

YesNo
(If yes describe)
Has your child had any of the following common childhood illnesses? ) Please check all that apply.

ConstipationFrequent ColdsSkin RashBronchitisHepatitisGerman measlesConvulsionsFrequent ear InfectionSoilingChicken PoxImpertigoPolioTuberculosisDiarrheaFrequent Sore throat LiceUpset StomachMeaslesScarlett FeverWhooping CoughFainting SpellsRingwormAsthmaHeart DiseaseMumpsUrinary ProblemsDiabetes
Does your child have any speech, hearing, or visual problems?

YesNo
(If yes describe)
Has your child been seen or tested for any of the above? (If yes describe)
Has your child ever had surgeries or do they have any prosthetic limbs etc.?

YesNo
(If yes, describe)
Would there be any restrictions to play or activities? I.e. child handicapped, allergic to grass, etc.?
General Emotional State of Health

How does your child show his/her feelings? (Answer below)
When afraid:
When happy:
When angry:
When Intolerant:
What forms of discipline are most often used in the child's home?
How does your child feel about daycare and being left by his/her mommy/daddy?
Are there any recent traumatic situations the child has been exposed to such as: (death in the family, divorce, newsiblings etc.? If yes, please describe:
How is your child easily settled when upset or afraid?
Are there any other comments or information you would like to let us know about?
Any specific concerns?
Parent Signature

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Parent Signature

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