Student Questionnaire

Last Name

First Name

Date of Birth Student

What form of child care has your child had previously? Please explain.

Does your child nap during the day? If so, at what time and for how long?

What signs of fatigue does your child exhibit?

Does your child have any dietary restrictions? If so, explain.

What signs of hunger does your child exhibit?

Has your child had group play experiences? If so, where and how often?

What are your child’s favourite indoor and outdoor activities?

Does your child experience any separation anxiety?

Does your child dress him or herself at home?

How do you discipline your child?

Is your child left or right handed?

Is your child toilet trained?

How would you describe your child’s personality?

What areas would you like to see your child’s potential more fully developed?

What past illnesses has your child had? At what age?

Chicken Pox Mumps Hepatitis Scarlett Fever Measles

Any complications?

Has your child had any serious accidents? Explain.

Does your child have allergies? If so, to what and how do they normally manifest themselves?

Does your child have frequent:

Tonsilitis Ear Aches Stomach Aches Nose Bleeds Colds

Please explain.

Does your child have any learning, behavioural or developmental needs?

Any other comments that you feel will assist us in the care of your child?

Please provide us the names and birthdays of parents, grandparents, siblings and other household members