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Child Assessment Form
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Child Assessment Form
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Child - General Information
Child's Name
First
Middle
Last
Enrollment Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Address
Street Address
City
Alabama
Alaska
American Samoa
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Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
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Montana
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New Hampshire
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New York
North Carolina
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Northern Mariana Islands
Ohio
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South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Health
Does your child have any allergies?
Yes
No
If so, what allergies does your child have?
How should we respond to an allergic reaction?
Does your child have an existing illness?
Yes
No
If so, what illness?
Has your child had a previous serious illness, injury, or hospitalization during the past 12 months?
Yes
No
If so, what illness, injury or hospitalization?
Is your child taking any medication?
Yes
No
If so, how is the medication administered?
Will the medication need to be administered while in care?
Yes
No
Is the medication prescribed for continuous use?
Yes
No
Are there any side effects we should be alerted to?
Yes
No
If so, what are the side effects?
Toileting
Does your child need assistance with toileting?
Yes
No
What are your ideas about toilet training?
How can we best assist?
Behavior
Does your child have any special fears?
Yes
No
If so, what are their fears?
How does your child communicate their fears/needs?
How do you tell your child to stop a behavior that you don't approve of or that might be dangerous?
When your child is upset what calms them down?
What is a good way to distract your child when they are having a temper tantrum?
Are there any particular routines that are helpful at naptime?
Yes
No
If so, what routine(s)?
What position is most comfortable for your child while they are napping?
Eating Preferences
What are your child's favorite foods?
Does your child use utensils, eat with fingers, or feed self?
Eats with utensils
Eats with fingers
Feeds themselves
Does your child choke easily while eating?
Yes
No
Activities
What activities do you like to do with your child?
What activities does your child like to do when playing with other children?
What does your child like to do when playing alone?
Additional Information
Tell us about your family (i.e., child's parents, siblings, grandparents, extended family, etc.).
More Information:
Parent Verification
Name
First
Last
Did the director of Learning Stages appropriately relay information concerning the child's assessment?
Yes
No
I verify this is information is accurate and correct.
Yes
No
Phone
This field is for validation purposes and should be left unchanged.
