Form LIC 702
CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT
Family Code/Account
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Email
*
Confirmation Email
Confirm your email by entering it twice
CHILD’S NAME
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Sex
*
Please Select
Male
Female
BIRTH DATE
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Month
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Day
Year
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)
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BEGAN TALKING AT (*Months)
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TOILET TRAINING STARTED AT (*Months)
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PAST ILLNESSES
Check illnesses that child has had and specify approximate dates of illnesses:
Past Illnesses (S1)
Rows
Yes?
Dates
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever
Past Illnesses (S2)
Rows
Yes?
Dates
Diabetes
Epilepsy
Whooping cough
Mumps
Past Illnesses (S3)
Rows
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?
*
YES
NO
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?
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Hour Minutes
AM
PM
AM/PM Option
WHAT TIME DOES CHILD GO TO BED?
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Hour Minutes
AM
PM
AM/PM Option
DOES CHILD SLEEP WELL?
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DOES CHILD SLEEP DURING THE DAY?
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WHEN?
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HOW LONG?
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DIET PATTERN (What does child usually eat for these meals?)
Rows
What does child usually eat?
BREAKFAST
LUNCH
DINNER
WHAT ARE USUAL EATING HOURS?
Rows
Usual Eating Hours
BREAKFAST
LUNCH
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?
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YES
NO
IF YES, AT WHAT STAGE
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ARE BOWEL MOVEMENTS REGULAR?
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YES
NO
WHAT IS USUAL TIME?
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WORD USED FOR “BOWEL MOVEMENT"
*
WORD USED FOR URINATION
*
PARENT’S EVALUATION OF CHILD’S HEALTH
IS CHILD PRESENTLY UNDER A DOCTOR’S CARE?
YES
NO
IF YES, NAME OF DOCTOR
DOES CHILD TAKE PRESCRIBED MEDICATION(S)?
YES
NO
IF YES, WHAT KIND AND ANY SIDE EFFECTS:
DOES CHILD USE ANY SPECIAL DEVICE(S)
YES
NO
IF YES, WHAT KIND
DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME?
YES
NO
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
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DATE
*
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Month
/
Day
Year
Date
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