Child's Individual Development Summary
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Social Emotional Development
Child's Full Name
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First Name
Last Name
Child's Date of Birth
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Month
-
Day
Year
Date
How would you describe your child's temperament?
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Does your child separate from you easily?
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Yes
No
Additional Information:
Does your child have any fears we should be aware of?
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Yes
No
Additional Information:
How do you comfort your child when they are hurt/sad/frightened?
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Does your child spend time with other children?
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Yes
No
Additional Information:
Who else lives in your home? Any pets, sibling, extended family, etc.?
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Health and Medical Information
Has your child had any major surgeries or procedures? If yes, please describe:
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Has your child been diagnosed with a serious illness? If yes, please describe:
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Does your child have any special needs we should be aware of? If yes, please describe:
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Has your child been diagnosed with any cognitive, developmental or physical conditions? If yes, please describe:
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Has your child been diagnosed with speech, visual, or hearing impairments? If yes, please describe:
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Has your child been involved in any serious accidents? If yes, please describe:
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Has your child experienced any type of trauma? If yes, please describe:
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Does your child suffer from allergies (non food-related) such as hay fever, animals, etc.? If yes, how do you manage them?
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Napping and Resting
What is your child's typical nap schedule?
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Does your child use any comfort items when sleeping? (e.g. Pacifier, special stuffed animal, etc.)
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Yes
No
Additional Information:
How do you help your child fall asleep? (e.g. Rubbing back, singing, etc.)
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Toilet/Diapers
Where on the scale would you say your child is at?
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Diapers
Some potty training
Really working at potty training
Some accidents
Fully potty trained
Is there anything you would like us to know about your child's elimination habits?
Communication
What is the language you primarily speak in your home?
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Do you speak other languages in your home?
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Yes
No
Additional information:
Do you use any sign language to communicate with your child?
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Yes
No
Additional information:
What is your child's age?
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Infant (6 weeks - 12 months)
13 months+
Nutrition
Infants (6 weeks - 12 months)
How many bottles a day does your child typically have?
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How many ounces per bottle?
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Breast milk or formula?
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If your child has begun eating solids, please list those approved baby food purees, infant cereal, and/or infant finger food here:
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What is your child's typical feeding schedule?
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Is there anything you would like us to know about your child's eating habits?
Nutrition
Children aged 13 months+
What are your child's favorite foods?
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What are your child's least favorite foods?
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What is your child's typical meal routine?
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General
Do you have any concerns for your child in terms of reaching their developmental milestones? (e.g. Cognitive, Social Emotional, Physical, Language)
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Would you like to share your cultural values with us? (e.g. Customs, celebrations, holidays, foods)
Signatures
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Signing Parent/Guardian Name
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First Name
Last Name
Signing Parent/Guardian Email
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example@example.com
Signing Parent/Guardian Signature
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Signing Parent/Guardian Date
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-
Month
-
Day
Year
Date
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