STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AGENCY COMMUNITY CARE LICENSING CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT CHILD’S NAME SEX BIRTH 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* BEGAN TALKING AT* TOILET TRAINING STARTED AT* MONTHS MONTHS MONTHS PAST ILLNESSES illnesses that child has had and specify approximate dates of illnesses: — DATES ☐ ☐ ☐ Chicken Pox Diabetes Poliomyelitis ☐ ☐ ☐ Ten-Day Measles Asthma Epilepsy (Rubeola) ☐ ☐ Rheumatic Fever Whooping cough ☐ Three-Day Measles ☐ ☐ Hay Fever Mumps (Rubella) SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS ☐ ☐ HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF YES NO DOES CHILD HAVE FREQUENT COLDS? DAILY ROUTINES (*For infants and preschool-age children only) WHAT TIME DOES CHILD GET UP?* WHAT TIME DOES GO TO BED?* DOES CHILD SLEEP WELL?* DOES SLEEP DURING THE DAY?* WHEN?* HOW LONG?* DIET PATTERN: BREAKFAST WHAT ARE USUAL EATING HOURS? (What does child usually BREAKFAST eat for these meals?) LUNCH LUNCH DINNER DINNER ANY FOOD DISLIKES? ANY EATING PROBLEMS? ARE BOWEL MOVEMENTS REGULAR?* WHAT IS USUAL TIME?* IS CHILD TOILET TRAINED?* IF YES, AT WHAT ☐ ☐ ☐ ☐ YES NO YES NO WORD USED FOR URINATION* WORD USED FOR MOVEMENT”* “BOWEL PARENT’S EVALUATION OF CHILD’S HEALTH * * * Free Preview End * * * Purchase Required To Gain Total Access Visit To Purchase Daycare Enrollment Forms
STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT CHILD’S NAME SEX BIRTH 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 — illnesses that child has had and specify approximate dates of illnesses: DATES ☐ Poliomyelitis ☐ Ten-Day Measles (Rubeola) ☐ Three-Day Measles (Rubella) ☐ Chicken Pox ☐ Diabetes ☐ Asthma ☐ Epilepsy ☐ Rheumatic Fever ☐ Whooping cough ☐ Hay Fever ☐ Mumps 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?* WHAT TIME DOES GO TO BED?* DOES CHILD SLEEP WELL?* DOES SLEEP DURING THE DAY?* WHEN?* HOW LONG?* DIET PATTERN: (What does child usually eat for these meals?) BREAKFAST WHAT ARE USUAL EATING HOURS? BREAKFAST LUNCH DINNER LUNCH DINNER ANY FOOD DISLIKES? ANY EATING PROBLEMS? IS CHILD TOILET TRAINED?* ☐ YES ☐ NO IF YES, AT WHAT ARE BOWEL MOVEMENTS REGULAR?* ☐ YES ☐ NO WHAT IS USUAL TIME?* WORD USED FOR “BOWEL MOVEMENT”* WORD USED FOR URINATION* PARENT’S EVALUATION OF CHILD’S HEALTH * * * Free Preview End * * * Purchase Required To Gain Total Access Visit To Purchase Daycare Enrollment Forms
childs-preadmission-health-history-parents-report.docx