Child Information Sheet

How long has child been with you?
Eating habits
a. Large or small appetite?
b. Likes or dislikes?
c. Slow or fast eater?
d. What are usual meal hours?
e. Feeds self or needs help? Handles knife, fork and spoon well? Cup or glass?
Sleeping Habits:
a. Usual bedtime and rising hour?
b. Naps? What time?
c. Goes to bed readily or stalls at bedtime? Is bedtime regular or are exceptions made for special occasions? (Please specify how frequently)
d. Is there a certain bedtime routine- such as bath first, bedtime story, particular toy or object taken to bed? Prayer at bedtime?
e. Sleeps in bed alone- in room alone- used to being with others? (If so, please specify whether this is child/children/adult.
f. Any fears of the dark?
g. Quiet, restless, light sleeper, heavy sleeper, nightmares?
h. Wants light on in room or hallway? Sleeps with door open or closed? Window open or closed? Shade up or down?
i. Gets up for drink or toilet during the night? Ay bedwetting or soiling? If so, how frequently?
Toilet Habits (Include any special routine the child has developed)
a. Goes to bathroom alone, or needs help?
b. Bowel movements: how frequently, what hour of the day? Any problems with constipation or diarrhea? If so, how is this handled? Any daytime soiling?
c. Any problems with urination, such as frequency when excited or daytime accidents? Able to “hold it”?
Dressing:
a. Does child dress self or attempt to do so? Need help with shoelaces, etc.?
b. Any preferences regarding color or type of clothing?
c. Used to picking out own outfit for the day?
d. Any sensitivities to fabrics or tags?
e. Is child hot or cold when other family members aren’t?
f. What size clothing does child wear?
Bathing:
a. Bathes self or has help?
b. How frequently does child have a full bath? Time of day?
c. Any special routine, like toy in tub, bubble bath, etc.?
d. Likes or dislikes bath?
e. Any special soap used? Does rash or very dry skin develop if certain soaps used? (If so, please specify brands)
Shampoo and Hair care:
a. How frequently is shampoo used? Is this done at bath time or in the sink?
b. Likes or dislikes shampoo? Afraid of soap in eyes? Wants towel to hold over eyes, or shampoo goggles?
c. Is hair cut at home, at barber or at hairdresser? Reaction to getting hair cut?
d. If child is a girl, is she used to hair dryers and rollers? Does she like having her hair “done”?
Dental Hygiene and Care:
a.Brushes own teeth? With or without reminders?
b.How often?
c.Any special brand of toothpaste or toothbrush?
d. Has child been to dentist? When was last check-up? Afraid of dentist?
e.Any dental problems?
Health
a. Date of last examination and name of doctor?
b. Has child ever been hospitalized to your knowledge? Age and reason?
c. Reaction to doctors and nurses (ex: fearful, enjoys going, anxious, cooperate during physical examination, fights exam or needles?)
d. Any know illnesses in past? Recently?
e. Any allergies to food or medicine?
f. Susceptible to colds, earaches, etc.? Runs high fever with colds, flu, etc.?
g. When ill, is there anything special the child likes (ex: certain foods, attention, snuggling, being left alone?)
h. Frequent ear infections? Breathing problems? Noise sensitivities?
i. Does child hear well?
j. Does child wear glasses? (If so, how long? Wears them all day or part of time? Objects to them? How often is there breakage?)
k. Give details of any special medical problems and treatment or care required.
Behavior
a. What is personality and disposition like? What does child do to express pleasure, anger? Reaction when denied something?
b. How does child get along with parents? Relatives? Any favorites or preferences for individuals or women vs. men?
c. If there are siblings, how do they get along? (Please include biological and foster siblings)
d. How does the child get along with other children? Age group or gender used to or prefers as playmates? Used to playing alone or with others?
e. What are favorite toys, games, activities?
f. Prefers playing indoors or out?
g. Any favorite books or stories?
h. How much time is spent watching television? What programs are watched regularly? Any problems regarding restricting time spent watching, or programs selected?
i. Does child play video games? If so, what kind? How long?
j. Any special behavior such as temper tantrums (and what specifically does child do then), breath holding, nail biting, head banging, fear of people or things, etc.?
k. Any aggression toward other children or pets?
l. What discipline is used? What is most effective and what does not work?
m. Physical development- does child have good muscular development and coordination or awkward, clumsy, etc.?
Miscellaneous
a. Right or left handed?
b. Is child used to house pets? If so, what kind and how does child treat them? Any fears of animals?
c. Is child used to attending Sunday school or church? If so, which church? How frequently? How does child handle service?
d. Are pictures of family, relatives, friends available which can go with child?
e. What if any household tasks does child do? Regularly, only if reminded, or under protest?
f. What names have special meaning to the child and who are they? Please list and identify (ex: neighbor, playmate, neighborhood bully, relative, pet, etc.)
g. What are child’s strengths?
h. What are child’s most bothersome behaviors?
School age child: (Indicate grade)
a. What hour does child leave for school and return?
b. How does child get to school? (walk, bus, driven?)
c. Lunch arrangements: take lunch, school lunch, comes home?
d. Any problems regarding school? (ex: does child go willingly? Hard to get up in the morning? Fail to come straight home?)
e. Favorite or particularly disliked subjects or teachers?
f. In regular or special education class?
g. Have an IEP?
Special services:
a. Does child receive any special therapy? (Ex: physical therapy, occupational therapy, sensory integration) How often? Does child handle therapy well? Who is therapist?
Additional comments- Is there anything else that would help us understand and transition the child?