The commonwealth of massachusetts department of Early Education and Care



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THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care




DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION
Regulations for licensed child care facilities require this information to be on file to address the needs of children while in care.

CHILD'S NAME: ___________________________________ DATE OF BIRTH: __________________
Please provide information for Infants and Toddlers (marked *) as appropriate to the age of your child.
DEVELOPMENTAL HISTORY

Age began sitting: ____________ crawling: ____________ walking: __________ talking: ___________

*Does your child pull up? ____________ *Crawl? _____________ *Walk with support? _____________

Any speech difficulties? _______________________________________________________________

Special words to describe needs ________________________________________________________

Language spoken at home _______________________ *Any history of colic? ____________________

*Does your child use 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 spoon?__________ Fork?__________ Hands?__________


TOILET HABITS

*Are disposable or cloth diapers used? ________*Is there a frequent occurrence of diaper rash?______

*Do you use: oil:_____ powder:_____ lotion:_____ other:_____________________________________

*Are bowel movements regular?______________________ How many per day?___________________

*Is there a problem with diarrhea?_____________________ Constipation? _______________________

*Has toilet training been attempted?______________________________________________________

*Please describe any particular procedure to be used for your child at the center: __________________

___________________________________________________________________________________

*What is used at home? Pottychair? ________ Special child seat? _________ Regular 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? ________________________________________________________




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