Child History Survery

Child's Full Name*
Child's Nickname (optional)
Child's Date of Birth*
Month
Day
Year
Does your Child have Siblings. If so, please list.
Sibling Name Age
Do both parents live at home?*
- Yes
- No
- Prefer not to say
Primary language spoken at home*
Does any other adult regularly care for your child? If so, please detail their relationship to your child and how often they care for them.
Has your child experienced any changes or new experiences? If so, please detail.
Examples of this would be Surgery, Illness, Birth of a Sibling, Hospitalization, Death in Family, Change in residence, etc.
Is your child toilet trained?*
- Yes
- No
Any allergic condition. If so, please list.
Does your child suffer from ear infections.*
Is your child taking medication(s). If so, please list.
Mediciation Reason Frequency
Have you noticed or suspected any physical difficulties in vision, hearing, coordination, etc.? Please explain.
How does your child react to new experiences?
How would you describe your child's willingness to communicate their feelings?*
- They will talk freely about what's on their mind
- They will open up is asked/approached about their feelings.
- They will keep things to themselves.
What are you child's favorite play activities? Please list.*
What opportunity does your child have to play with other children? Please explain.
Has your child been a member of a play group?*
- Yes
- No
Is your child able to play alone?*
- Yes
- No
Is there anything you would like the teachers to be aware of concerning your child?
What do you hope your child will gain from attendance at St. Paul's Day School?*

Sibling Name	Age

Mediciation	Reason	Frequency