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MHPC Application-ChildsHistory-1

MHPC Application-ChildsHistory-1

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Published by Adrianne Wallace

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Published by: Adrianne Wallace on Feb 14, 2011
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08/25/2015

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1

Merry Hearts Play Circle
zc8 S. Suntu le Lrlve, 8llllngs, M1 ¸ç¡cz µc66µ,c¡¡6


Aµµllcutlon: !"#$%&' )#'*+,-

Lute: ________________
Nume of chlld: __________________________________________ 8lrthdute: _____________
Numes und uges of slbllngs:
_____________________________________________________________________________
vho does the chlld llve wlth? Mother ___luther ___ 8oth ___ Cther: ___________________
Are there uny other udults or chlldren llvlng ln the home? lf so, µleuse descrlbe the sltuutlon:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
ls thls your flrst exµosure to u vuldorf tyµe educutlon? (Pleuse Clrcle) Yes j No
lf not where else hus your chlld uttended u slmllur µrogrum? ___________________________
_____________________________________________________________________________
Lescrlbe other µrogrums the chlld hus been ln, lf uny (gymboree, urt, muslc, µluygrouµ):
_____________________________________________________________________________
Loes your fumlly huve uny µets? Pleuse llst klnds & numes. ____________________________
_____________________________________________________________________________

_____________________________________________________________________________

ls the chlld udoµted? ____________ lf yes, ut whut ugejwhut clrcumstunces? ____________
vus the chlld breust fed, bottle fed or both? ________________________________________

Eus the chlld been comµletely weuned? ____________ At whut uge? ___________________
Loes the chlld µut objects ln hlsjher mouth? ________________________________________
Lld the chlld cruwl? _______ At whut uge? ___________ lor how long? __________________
2
Lld hejshe use u buby wulker? __________ swlng? __________ bouncer? __________
At whut uge dld the chlld wulk wlthout suµµort?_____________________________________
Loes the chlld use the tollet lndeµendently?________________________________________
_____________________________________________________________________________
!"#$%&'" )*" $*&+,-# .//")&)"0 1%" )*"%" .23 455, .++"%6&"#7 455,# )5 .85&,7 4.85%&)" 455,#9
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
1endency towurd: sweet _____ sour _____ bltter _____ sulty _____
!"#$%&'" )*" $*&+,-# #+""/ /.))"%2#:
_____________________________________________________________________________
_____________________________________________________________________________
Loes the chlld sleeµ soundly through the nlght? _____________________________________
ls bedtlme eusy or chullenglng? __________________________________________________
vhut tlme does the chlld go to bed? veeknlght? ____________ weekend? ______________
vhut tlme does the chlld uwuke ln the mornlng? ____________________________________
Loes hejshe wuke uµ slowly or qulckly ln the mornlng? _______________________________
Loes the chlld nuµ? _____lf so, ut whut tlme und for how long? ________________________
lf not, ut whut uge dld hejshe stoµ? _______________________________________________
Loes the chlld huve hlsjher own bedroom? _________________________________________
Loes the chlld huve nlghtmures? _________________________________________________
;*&+,*55, &++2"##"#:
Eus your chlld ever hud uny of the followlng lllnessess? Pleuse llst dutes:
Chlcken µox ___________ Rubellu __________ Mumµs __________ Meusles __________
Scurlet fever __________ vhooµlng cough __________
Eow often does the chlld get slck? Pleuse descrlbe your chlld's tyµlcul heulth:
_____________________________________________________________________________
_____________________________________________________________________________
3
Are there uny other heulth or develoµmentul conslderutlons? (l.e. drug ullergles or unusuul
µhyslcul condltlons)
___________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
Pleuse glve me u µlcture of your fumlly llfe slnce the chlld's blrth, (use buck slde lf needed),
such us house moves, truvel to u forelgn country, deuth of u relutlve close to the chlld,
seµurutlon lssues... _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Loes the chlld become uµset euslly? __________ lf so, whut seems to µrovoke thls?
_____________________________________________________________________________
_____________________________________________________________________________
Eow do you dlsclµllne the chlld? __________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Loes the chlld wutch televlslon? ________ hours µer duy __________ µer week ___________
Loes your chlld wutch vldeos? _________ hours µer duy __________µer week___________
vhut tyµe of µrogrums does your chlld wutch?
_____________________________________________________________________________
_____________________________________________________________________________
vhut does the chlld llke to do? Lescrlbe some of hlsjher fuvorlte thlngs:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
vhut do the µurents or other cure glvers llke to do wlth the chlld?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4

Pleuse udd unythlng else you would llke me to know ubout your chlld or feel ls lmµortunt to
hlsjher udjustment wlth me. Use sµuce below lf needed.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

1hunk you so much for your effort ln comµletlng thls form. Your chlld ls µreclous und thls
lnformutlon ls solely used to helµ me suµµort hlsjher needs und uµtltudes.
Purent's slgnuture __________________________________________ Lute____________

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