Developmental History | Nursery School | Washington University in St. Louis

Washington University Nursery School Developmental History

We ask that you complete the following questionnaire. Our goal is that the information you provide will help us better understand your child and his/her development. If there are any questions you feel uncomfortable answering, please feel free to leave that question blank.
Thank you,
Nikki Scheele, Director

Date

Child's Name

First/Middle/Last

Date of Birth

Place of Birth

Parent/Guardian

First & Last Name

Parent/Guardian

First & Last Name

Sibling(s)

First & Last Name

DOB

Sibling(s)

First & Last Name

DOB

How does your child relate to his or her brothers/sisters?

Members of your present household (include parents, children, relatives, roomers, housekeepers, etc.)

Ethnicity

Language spoken in child's home

Is your child adopted?

Yes

If adopted, at what age?

Have you discussed the adoption with your child?

Yes

Are there other adults responsible for the care of your child?

Have you used babysitters?

Yes

Does your child have playmates? How many? Ages? Boys, girls or both?

Is your child timid with children? Timid with adults?

Yes

What activities does your child enjoy doing at home?

What fears does your child have (i.e fear of the dark, animals, etc.)?

How do you handle your child's fears?

What comforts your child when he/she is upset (hugs, favorite thumb, etc.)?

What forms of discipline do you use? How does your child react to these?

Is your child easily over stimulated?

Does your child take a nap? Average length of nap?

Does your child go to sleep easily? Is your child subject to night disturbances?

Is your child toilet trained? (This is not required for attendance.) Does your child have any toileting problems?

Has your family moved recently?

Medical Background:

How is your child's general health?

Does your child have any allergies? For your child's safety, these allergies will be posted in your child's clssroom. (If you object to this information being posted, please contact the director.) If yes, please provide instructions on treatment.

Does your child have any serious medical conditions?

Is your child receiving any daily medications?

Has your child been hospitalized?

Child Development: If you answer "yes" to any of the following questions, please describe.

Does your child have any difficulty speaking?

Does your child have any hearing or vision difficulties?

Are you concerned about your child's motor or physical development?

Has a doctor or other professional been consulted?

Does your child receive any early intervention services, such as speech therapy, physical therapy, occupational therapy, etc.?

Has your child had any previous group experience? If so, please describe where, when, for how long). What was your child's response?

What kind of adjustment do you expect your child to make in his/her first experiences in nursery school?

Additional information about your child that you think would help us better understand him or her.

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