TAKEN FROM LIC 702 CHILD'S PREADMISSION HEALTH HISTORY: PARENT'S REPORT FATHER'S/LEGAL REPRESENATIVE FULL NAME
DOES FATHER/LEGAL REPRESENTATIVE LIVE IN HOME WITH CHILD?
MOTHER'S/LEGAL REPRESENTATIVE FULL NAME
DOES MOTHER/LEGAL GUARDIAN LIVE IN HOME WITH CHILD?
IS/HAS THE CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN?
DATE OF LAST PHYSICAL EXAMINATION
CHILD WALKED AT (age in months)
CHILD BEGAN TALKING (age in months)
TOILET TRAINING BEGAN AT (age in months)
PLEASE CHECK ALL THAT APPLY AND SPECIFY THE APPROX. DATES BELOW IN THE BOX PROVIDED.
PLEASE SPECIFY THE APPROX. DATES OF PAST ILLNESSES HERE.
PLEASE SPECIFY ANT OTHER SERIOUS ILLNESS OR ACCIDENTS HERE
PLEASE LIST ALL ALLERGIES WE NEED TO BE AWARE OF.
YOUR CHILD'S DAILY ROUTINES PLEASE SHARE YOUR CHILD'S SLEEPING PATTERNS. WHAT TIME DOES YOUR CHILD WAKE UP AND WHAT TIME DOES YOUR CHILD GO TO BED? DOES YOUR CHILD SLEEP WELL THROUGH THE NIGHT? DOES YOUR CHILD NAP? IF YES, WHAT TIME AND HOW LONG?
PLEASE SHARE YOUR CHILD'S EATING PATTERNS. WHAT DOES YOUR CHILD USUALLY EAT FOR BREAKFAST, LUNCH AND DINNER? WHAT TIMES DOES YOUR CHILD TYPICALLY EAT THESE MEALS?
PLEASE SHARE FOODS YOUR CHILD IS OR MAY BE ALLERGIC TO. ALSO LIST FOODS YOUR CHILD DISLIKES.
PLEASE SHARE YOUR CHILD'S BATHROOM CARE AND HABITS. IS YOUR CHILD POTTY TRAINED? IF YES, AT WHAT STAGE. ARE YOUR CHILD'S BOWEL MOVEMENTS REGULAR? WHAT TIME ARE THEY GENERALLY? WHAT WORDS DOES YOUR CHILD USE FOR URINATION AND BOWEL MOVEMENTS?
PLEASE SHARE YOUR EVALUATION OF YOUR CHILD'S OVERALL HEALTH.
IS YOUR CHILD PRESENTLY UNDER A DOCTOR'S CARE? IF YES, NAME OF THE DOCTOR AND ANY MEDICATIONS YOUR CHILD IS TAKING ALONG WITH ANY SIDE EFFECTS.
DOES YOUR CHILD REQUIRE OR USE ANY SPECIAL DEVICES? YES OR NO? IF YES, WHAT KIND.
PARENT'S/LEGAL GUARDIAN'S EVALUATION OF YOUR CHILD'S PERSONALITY. HOW DOES YOUR CHILD GET ALONG WITH YOU, SIBLINGS, AND OTHERS? HAS YOUR CHILD HAD ANY LARGE GROUP EXPERIENCES? DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD'S SOCIAL BEHAVIOR?
DO YOU HAVE A PLAN FOR YOUR CHILD'S CARE WHEN THEY ARE SICK AND CANNOT ATTEND SCHOOL?
PARENT/LEGAL GUARDIAN SIGNATURE Modo de dibujo seleccionado. Para dibujar, necesitas un mouse o un panel táctil. Usa la función de accesibilidad del teclado al seleccionar Escribir o Subir.