Tiny Tots 
Preschool 

                   WE MAKE LEARNING FUN!


THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care



DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION



Regulations for licensed child care facilities require this information to be on file to address any needs of children while in care.


CHILD’S NAME _______________________________________ DOB _______________________


DEVELOPMENTAL HISTORY


Age began sitting: ______ crawling:_______ walking:  _______ talking:  ________

Speech difficulties?  ________________________________________________________________

Special words to describe need: _______________________________________________________

Spoken language:  ____________________

Difficulty with speech? ___________  Programs attended: ___________________________________


HEALTH

Special physical conditions, disabilities, or allergies: _________________________________________

Regular medications: ______________________________  Frequency:  ________________________


EATING HABITS 

Describe favorite foods and foods refused _________________________________________________


TOILETING 

 How does child indicate bathroom needs (special words)? ____________________________________

 Is child reluctant to use bathroom? ____________ Age child trained ___________ 

Does child have accidents? __________ How frequently? _____________________________________


SLEEPING HABITS Does child have any difficult sleep patterns? _______________________________

 How often does child nap? ______________________________


SOCIAL RELATIONSHIPS 

How does child react to new social situations?_______________________________________________ 

Previous experience with children or schools ________________________________________________ 

Reaction to strangers _____________________________ 

Ability to play alone _____________________ 

Favorite toys or activities ________________________________________________________________ 

Fears and anxiety provoking situations _____________________________________________________ 

How is child comforted? _________________________________________________________________ 

How is child disciplined? _________________________________________________________________

What would you like your child to gain from this school experience? _______________________________ _____________________________________________________________________________________

Is there anything else you would like us to know about your child? ________________________________

_____________________________________________________________________________________



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PARENT’S SIGNATURE
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