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.
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? __________________________________________________________
Any known complications at birth? _______________________________________________________