Developmental History 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. Thank you! 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 No If adopted, at what age? Have you discussed the adoption with your child? Yes No Are there other adults responsible for the care of your child? Have you used babysitters? Yes No Does your child have playmates? How many? Ages? Boys, girls or both? Is your child timid with children? Timid with adults? Yes No What activities does your child enjoy doing at home? What toy or activity is your child passionate about in his/her play? What draws your child into play - either solo or in group play? 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 stuffy, 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? Can your child occupy herself/himself, and for how long? Does your child become frustrated easily? If yes, explain. How does your child express frustration? What makes your child angry, and how does she/he express anger? When your child exhibits big feelings/challenges, how do you and your child process that? What three descriptive words would you use to describe your child? How do you and your family spend time toegther? Does your child accept responsibilities willingly, (for example: putting away toys, completing household tasks, or non-preferred activities, etc.)? If no, please elaborate. How much screen time (tablet, TV, iPhone) does your child have each day/week? Medical Background: How is your child's general health? Does your child have any allergies? If yes, please provide a medical action plan on how to treat child completed by child's pediatrician. 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 or been tested for speech and language delays? Which of these best describes your child's speech? Speaks clearly most of the time Has some difficulty making self understood Hard to understand, especially by those outside the family Does your child have any hearing or vision difficulties? Does your child have any motor or physical delays or been tested for motor concerns? Has a doctor or other professional been consulted about any concerns? Has your child received any early intervention services, such as speech therapy, physical therapy, occupational therapy? 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. Signature * Type your name Date * Captcha Submit Δ