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Date

Name of Child

Date of Birth

Home Address

Phone Number

The last four digits of your Social Security Number

Mother/Father/Guardian's name

Email Address

How did you hear about us?

Does your child have any of the following? Please check

Allergies
Vomiting
Skin Problems
Eating Problems
Mental Disability
Physical Disability
Frequent Sore Throats/Colds
Epilepsy
Autism
Diarrhea
Ear Infections
Bleeding Disorders
Diabetes

If other chronic conditions, please give specific information:

Does your child have any birthmarks or other identifying marks on the body?

What illnesses has your child had in the past month?

What treatment was given?

Does your child have any special needs or behaviors we need to be aware of?

Other children in family (list relation):

Other adults in family (list relation):

Breakfast for the child usually consist of

Time the child usually eats breakfast

Time the child usually wakes up from nap is

Your routine for putting the child to sleep is

He/She likes to sleep on their Stomach, Back or Side

Is your child toilet trained?

What words does he/she use for the bathroom?

Play Habits

Eating Behavior:

Fears:

Likes and Dislikes:

Sleeping Pattern:

By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named child, and are over the age of 18. ELECTRONIC SIGNATURE, INITIALS PLEASE *

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