KIDS MEDICATION & SPECIAL

KIDS MEDICATION & SPECIAL

CONDITIONS QUESTIONNAIRE
A questionnaire must be filled out for each child coming to the Kids Club. Please fill in the fields of the following questions. You can leave empty those which does not affect your child
Child's Name*
Date of Birth

DayMonthYear
Disability, if any
Special needs or health issues we need to know about for Kids Club activities such as swimming, going out in the sun, going for walks, running while playing games, etc.?
Medications: Parents MUST provide and give all medications to their own children. List all medication your child/children take, times given, as well as possible side effects
Allergies: Please list any allergies your child has.
Foods
Medications
Insects
Lotions
Other
Toileting: Please indicate your child's toileting habits. Be as specific as possible.

DiapersToilet TrainingTrained w/assistanceIndependent
Explain your child's toileting schedule or assistance needed, if any
Communication: Please indicate your child's communication skills. Be as specific as possible.

VerbalNon-verbalSign LanguageCommunication BoardPECS (Picture Exchange Communication System)
Please circle current PECS level

123
Understands and follows simple directions:
(please check one)

neversometimesalways
Tell us more if you need
Feeding/Eating: Please indicate your child's feeding/eating level. Be as specific as possible.

G-tubewith assistanceIndependentVegetarian diet needed
Food they CANNOT have
Special feeding instructions
Assistive technology/Specialized equipment: Please list all equipment your child is bringing to the KIDS CLUB.
Additional information: Please be as specific as possible
List things your child likes to do, what quiets him/her, or really upsets him/her. How is/are he/she in new places, with new people?
List things your child would NOT be allowed to do
Tell us about your child's daily routines (schedules, nap times, snack routines, etc.)
Does your child have hearing/vision problems? Please explain.
How does your child act in a group setting?
Does your child have any behavior issues (biting, hitting, self abusive, etc.)?
How do you handle the behaviors?
Current Date*

DayMonthYear
Signature

Clear
Should be Empty: