HAMMONDS PLAINS CHILDREN'S CENTRE
#1 Yankeetown Road, Hammonds Plains, NS
B3Z 1K7 Canada, http://www.turbokids.ca
Ph +1 902 835 1804, Fax +1 902 835 1484

Child's Health Questionaire

Name of Child:___________________________________________ Date:___________________


Provincial Health Card Number:_______________________________Expiry :__________________
1. In Case of Emergency

Adult to contact if you can not be reached:

Name:_________________________________________________Relationship:______________

Telephone (work): _____________________________ (home):_____________________________
2. Physician and/or Clinic

Name:_______________________________________________Telephone:__________________________

Address:________________________________________________________________________________

_______________________________________________________________________________________
3. Immunization Record

DPTP + HIB 2 months_______________________________

4 months_________________________________________

6 months_________________________________________

18 months________________________________________

MMR 12 months____________________________________

DPTP 4-6 years____________________________________

Other Immunizations:

________________________________________________

________________________________________________

________________________________________________

________________________________________________
4. Dentist/Clinic

Name:___________________________________________Telephone:________________________________

Address:___________________________________________________________________________________

_________________________________________________________________________________________
5. Background Information

Please list any other children in the household. First name (last name only if different):

1._________________________________________Age____________

2._________________________________________Age____________

3._________________________________________Age____________

Language(s) spoken at home:______________________________________________________

Has your child been in a child care arrangement before: Yes__ No__

If your child has been cared for by family members or others (e.g., a neighbour), please describe the child's experience:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

If your child has had a group play experience, please describe how often your child attended, how long and your child's experiences:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
6. Health and Developmental History

Describe any difficulties or serious illnesses at birth, if any:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Describe your child's general health (e.g. recurrent colds, ear infections, stomach-aches, etc.):

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


If your child is taking any medication, what medication and what it is for:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


Has your child ever been to a dentist: Yes__ No__

Does your child have any dental problems:_________________________________________________

__________________________________________________________________________________________

Describe how your child communicates:

___________________________________________________________________________________________

___________________________________________________________________________________________

How would you describe your child's emotional, physical and social growth, and development to this point:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

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

Fluids/Beverages:_____________________________________________________________________________

Solids:______________________________________________________________________________________

Food allergies:_____________________________________________________________________

Has your child eaten peanut butter at home: Yes__ No__

Diet restrictions (cultural, religious):

____________________________________________________________________________________________

____________________________________________________________________________________________

Describe your child's sleeping habits and routine:

____________________________________________________________________________________________

____________________________________________________________________________________________

How frequently does your child have a bowel movement:

____________________________________________________________________________________________

How far has your child progressed in toilet learning, if applicable:

____________________________________________________________________________________________
7. Behaviour Patterns and Habits

Describe your child's behaviour and habits (e.g. temperament, energy level):

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Describe an ordinary day in your child's life, from getting up in the morning to going to bed, including the times for naps, meals and play, interests, activities, etc.:

Morning:______________________________________________________________________________________

_____________________________________________________________________________________________

Afternoon:_____________________________________________________________________________________

_____________________________________________________________________________________________

Evening:_______________________________________________________________________________________

______________________________________________________________________________________________

Describe any child's particular attachments (e.g. toy, blanket, pet, person) and any particular habits
(e.g. thumb-sucking, rocking):

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Describe any particular fears your child has shown (e.g., to animals, loud noises, strangers):

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


Describe how your child reacts to stressful situations (e.g., cries withdraws, has tantrums, nightmares):

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

How does your child usually react to new situation:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


We would appreciate your view on guiding your child's behaviour and setting limits:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


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

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


Parent's Signature:__________________________________________Date:_________________________________
2006-10-27 - Hammonds Plains Children's Centre Inc.