Health Questionnaire

Child's Name

Child's Health Card Number

Expiry Date

Immunization Records

Immunization Record (please give specific dates (y/m/d)
(Please note if you have chosen not to Immunize, we require a parent letter stating such with your signature )

DaPTP& HIB (Haemophilus Influenza conjugate Vaccine)

DaPTP& HIB 2 Months

DaPTP& HIB 4 Months

DaPTP& HIB 6 Months

DaPtP (Diphtheria, acelluar, Pertussis,Tetanus, & Polio vaccine)

DaPtP 2-6 years

MMR (Measles, Mumps, Rubella vaccine)

MMR 1 year

MMR 4-6 years

Varicella (Chicken pox)

Varicella 1 year (Or 4-5 years prior to school l entry)

Please Note the following:

DaPTP and Hib are combined in a single injection at 2, 4, 6, and 18 months of age. Varicella is now recommended at 12 months of age.
Please inform director of new immunization dates as they occur.
If you are choosing not to immunize your child/children, please contact the director to fill in a waiver form. A doctor’s note will be required.

Please provide the name of your child’s current physician and dentist if your child has been seeing one.

Name of Doctor

Contact Number

Clinic Address

Name of Dentist

Contact Number

Clinic Address

Please list the other children in the household:

Name 1

Age

Name 2

Age

Name 3

Age

Name 4

Age

Languages spoken at home

Has your child been cared for by others (Relatives, Neighbours)?

Yes No

If your child has had a group play experience, please describe how often our child was attending and what that experience was like

(1) Describe any difficulties or serious illnesses that we need to be aware

(2) Describe your child’s general health (i.e. colds, infections,)

(3) Are there presently any serious medical problems?

Yes No

If YES please describe the medical problem:

If your child is taking any medication, what medication is it?

(4) Has your child been to a dentist?

(5) Does your child have any dental problems? Please describe

(6) Describe how your child communicates:

(7) How would you describe your child’s emotional, physical, social and cognitive growth to this point?

(8) How does your child respond to sensory activities?

(9) Has your child been exposed to a group setting with children?

(10) How does your child respond to loud noises?

(11) Please describe any trauma during pregnancy that is known?

(1) Describe your child’s diet (include types of food and fluids she or he is now taking):

PLEASE LIST ALL ALLERGIES (food and medication)

(2) Describe how your child reacts and list the symptoms if known:

(3) Has your child eaten peanut butter at home?

Yes No

(4) Diet restrictions: (cultural, religious) (Please List Foods)

(5) Describe any particular concerns you have about your child’s diet: ( food intolerances/ sensory/ choking concerns)

(6) How frequently does your child have a Bowel Movement?

(7) How far has your child progressed in toilet training?

(1) Describe your child’s behaviour and habits (i.e. Temperament, energy level)

(2) Describe an ordinary day in your child’s life:

(3) Describe your child’s particular attachments (toy, blanket, pet) Any Habits?

(4) Describe any particular fears your child has shown (i.e. animals, loud noises, strangers)

(5) Describe how your child reacts to stressful situations (i.e. cries/ temper)

6) How does your child react to new situations?

We would appreciate your views on guiding your child’s behaviour and setting limits for behaviour management:

Is there anything else that you would like to tell us about your child to help us provide the best care possible?

Signature

Date

Parents/Guardian Acknowledgement: