D8 Form LIC 702

Form LIC 702

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
Family Code/Account*
Email*

Confirmation EmailConfirm your email by entering it twice
CHILD’S NAME*
Sex*
BIRTH DATE*

MonthDayYear
Date
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY

(*For infants and preschool-age children only)
WALKED AT (*Months)*
BEGAN TALKING AT (*Months)*
TOILET TRAINING STARTED AT (*Months)*
PAST ILLNESSES

Check illnesses that child has had and specify approximate dates of illnesses:

Past Illnesses (S1)

	Yes?	Dates
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever

Past Illnesses (S2)

	Yes?	Dates
Diabetes
Epilepsy
Whooping cough
Mumps

Past Illnesses (S3)

	Yes?	Dates
Poliomyelitis
Ten-Day Measles (Rubeola)
Three-Day Measles (Rubella)

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT COLDS?*

YESNO
HOW MANY IN LAST YEAR?
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
DAILY ROUTINES

(*For infants and preschool-age children only)
WHAT TIME DOES CHILD GET UP?*

Hour Minutes

AM/PM Option
WHAT TIME DOES CHILD GO TO BED?*

Hour Minutes

AM/PM Option
DOES CHILD SLEEP WELL?*
DOES CHILD SLEEP DURING THE DAY?*
WHEN?*
HOW LONG?*

DIET PATTERN (What does child usually eat for these meals?)

	What does child usually eat?
BREAKFAST
LUNCH
DINNER

WHAT ARE USUAL EATING HOURS?

	Usual Eating Hours
BREAKFAST
LUNCH
DINNER

ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?*

YESNO
IF YES, AT WHAT STAGE*
ARE BOWEL MOVEMENTS REGULAR?*

YESNO
WHAT IS USUAL TIME?*
WORD USED FOR “BOWEL MOVEMENT"*
WORD USED FOR URINATION*
PARENT’S EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?

YESNO
IF YES, NAME OF DOCTOR
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?

YESNO
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
DOES CHILD USE ANY SPECIAL DEVICE(S)

YESNO
IF YES, WHAT KIND
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?

YESNO
IF YES, WHAT KIND
PARENT’S EVALUATION OF CHILD’S PERSONALITY
HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?
HAS THE CHILD HAD GROUP PLAY EXPERIENCES?
DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN)
WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL?
REASON FOR REQUESTING DAY CARE PLACEMENT
Signature*

Clear
DATE*

MonthDayYear
Date
Should be Empty: