Date
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MM
DD
YYYY
Child's Name
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First Name
Last Name
Child's Gender
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Child's Date of Birth
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MM
DD
YYYY
Name of Parent #1
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First Name
Last Name
Address of Parent #1
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone of Parent #1
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(###)
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Cell Phone of Parent #1
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(###)
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Email of Parent #1
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Employer of Parent #1
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First Name
Last Name
Position of Parent #1
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Work Address of Parent #1
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Phone of Parent #1
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(###)
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Birthday of Parent #1
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MM
DD
YYYY
Name of Parent #2
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First Name
Last Name
Address of Parent #2
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone of Parent #2
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(###)
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Cell Phone of Parent #2
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(###)
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Email of Parent #2
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Employer of Parent #2
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First Name
Last Name
Position of Parent #2
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Work Address of Parent #2
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Phone of Parent #2
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(###)
###
####
Birthday of Parent #2
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MM
DD
YYYY
Name, Ages, and Birthdays of Siblings
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Other People Living At Home With Your Child
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Languages Spoken At Home
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Pets and Their Names
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What were your child’s birth circumstances? (home or hospital, length of labor, breech, premature, etc.)? Would you describe your child’s labor and birth time as easy or more challenging? Apgar score? Please describe.
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Are there any congenital conditions?
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Please explain any unusual or pertinent information regarding hearing.
Please explain any unusual or pertinent information regarding speech.
Please explain any unusual or pertinent information regarding eyesight.
Please explain any unusual or pertinent information regarding coordination/movement.
Please explain any unusual or pertinent information regarding persistent fears.
Please explain any unusual or pertinent information regarding learning difficulties,
Please explain any unusual or pertinent information regarding feeding difficulties.
Please explain any unusual or pertinent information regarding sleep difficulties.
Please explain any unusual or pertinent information regarding digestive difficulties.
Does your child have any on-going medical condition? Take any medication regarding this?
Has your child ever had a seizure of any kind? Please describe and give dates and comments.
Describe any accidents, serious illness or operations, with dates.
Have there been any severe illnesses or deaths involving people or pets close to your child?
What are their favorite foods?
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Is your family vegetarian, vegan, kosher, and/or gluten free?
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Any medically diagnosed food allergies? I NEED A DOCTORS NOTE, ON RECORD, SPECIFYING THE ALLERGY AND THE REPLACEMENT FOOD. PLEASE SUPPLY AN EPI PEN IF WARENTED
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May we serve: eggs, yogurt, cheese, tuna, cow’s milk, coconut milk, almond milk, herbal tea, chicken, and/or chicken broth?
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Has your child had any nut butters yet? Peanut? Almond or sunflower? May we serve them?
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Breakfast: What is a typical breakfast before school? What time does your child eat this meal?
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Lunch: What is a typical lunch?
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Dinner: What time is dinner? Is it always the same time? Is everyone there for dinner (or do children eat separately, or does one family member often have to miss the meal)? What type of meal is eaten (light, substantial, vegetarian, meat, fish, etc.)?
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Nursing: Are you still nursing? How often? Does your child have a favorite time to nurse? Does he or she fall asleep nursing? Does your child have a bottle at any time during the day or night? Or a pacifier?
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Sleep Habits: Napping schedule? Any lovey, pacifier, etc. Does your child sleep in a crib or a bed?
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Do you have a bedtime ritual? What time does your child go to bed at night? Fall asleep? Wake up in the a.m.?
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Is she or he alone in room? In a shared room? Your room? Family bed?
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Is your child’s sleep typically unbroken?
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Do you have any concerns or issues about your child’s bedtime and naptime?
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Discipline: How do you manage behavior/set boundaries at home?
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Special Needs: Any special movement related, physical, emotional, or medical needs that we should be aware of?
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Festivals/Holidays: We would love to know what and how you celebrate at home?
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Birthdays - We would love to know when your (the parents’) birthdays are? And Grandparents--especially if they are part of your family’s daily life.
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Please add anything you think is important to share with us about your child.
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