STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING

CHILD’S PREADMISSION HEALTH HISTORY—PARENT’S REPORT

CHILD’S NAME SEX
BIRTH DATE
FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME
DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME
DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?
IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL/MEDICAL EXAMINATION
DEVELOPMENTAL HISTORY (
*
For infants and preschool-age children only)
WALKED AT
*
MONTHS
BEGAN TALKING AT
*
MONTHS
TOILET TRAINING STARTED AT
*
PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses:
DATES
DATES
☐ Poliomyelitis
☐ Ten-Day Measles
(Rubeola)
☐ Three-Day Measles
(Rubella)
DATES
☐ Chicken Pox
☐ Diabetes
☐ Asthma
☐ Epilepsy
☐ Rheumatic Fever
☐ Whooping cough
☐ Hay Fever
☐ Mumps
SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS
DOES CHILD HAVE FREQUENT COLDS?
☐
YES
☐
NO
HOW MANY IN LAST YEAR?
LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF
DAILY ROUTINES (*For infants and preschool-age children only)
WHAT TIME DOES CHILD GET UP?
*
WHAT TIME DOES CHILD GO TO BED?
*
DOES CHILD SLEEP WELL?
*
DOES CHILD SLEEP DURING THE DAY?
*
WHEN?
*
HOW LONG?
*
DIET PATTERN:
(What does child usually
eat for these meals?)
BREAKFAST
WHAT ARE USUAL EATING HOURS?
BREAKFAST
LUNCH
DINNER
LUNCH
DINNER
ANY FOOD DISLIKES?
ANY EATING PROBLEMS?
IS CHILD TOILET TRAINED?
*
☐ YES ☐ NO
IF YES, AT WHAT STAGE:
*
ARE BOWEL MOVEMENTS REGULAR?*
☐ YES ☐ NO
WHAT IS USUAL TIME?*
WORD USED FOR “BOWEL MOVEMENT”
*
WORD USED FOR URINATION
*
PARENT’S EVALUATION OF CHILD’S HEALTH
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