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Child’s Preadmission Health History
LIC 702 Child Preadmission Health History
California DSS LIC 702 form.
Comments
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Child’s Preadmission Health History - Parent/Authorized Representative Report
California Department of Social Services LIC 702
Child's Name
(Required)
First
Last
Sex
(Required)
Male
Female
Birthdate
(Required)
MM slash DD slash YYYY
Parent/Authorized Representative #1
(Required)
First
Last
Parent #1 Lives in Home With Child?
Yes
No
Parent/Authorized Representative #2
First
Last
Parent #2 Lives in Home With Child?
Yes
No
Child Under Regular Physician Supervision?
Yes
No
Date of Last Physical/Medical Examination
MM slash DD slash YYYY
Developmental History (Infants and Preschool Age Children)
Walked At (Months)
Began Talking At (Months)
Toilet Training Started At (Months)
Past Illnesses
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever
Diabetes
Epilepsy
Whooping Cough
Mumps
Poliomyelitis
Ten-Day Measles (Rubeola)
Three-Day Measles (Rubella)
Approximate Dates of Illnesses
Other Serious Illnesses or Accidents
Does Child Have Frequent Colds?
Yes
No
How Many Colds in Last Year?
Allergies Staff Should Be Aware Of
Daily Routines
What Time Does Child Get Up?
What Time Does Child Go To Bed?
Does Child Sleep Well?
Does Child Sleep During the Day?
When Does Child Sleep During Day?
How Long Does Child Sleep During Day?
Breakfast Diet Pattern
Lunch Diet Pattern
Dinner Diet Pattern
Usual Breakfast Time
Usual Lunch Time
Usual Dinner Time
Food Dislikes
Eating Problems
Is Child Toilet Trained?
Yes
No
Toilet Training Stage
Are Bowel Movements Regular?
Yes
No
Usual Bowel Movement Time
Word Used for "Bowel Movement"
Word Used for Urination
Parent Evaluation of Child's Health
Child Currently Under Doctor Care?
Yes
No
Doctor Name
Does Child Take Prescribed Medication?
Yes
No
Medication and Side Effects
Does Child Use Special Devices?
Yes
No
Special Device Type
Does Child Use Special Devices at Home?
Yes
No
Special Device Type at Home
Parent Evaluation of Child Personality
How Child Gets Along with Family and Others
Group Play Experiences
Special Problems/Fears/Needs
Plan for Care When Child is Ill
Reason for Requesting Day Care Placement
Parent/Authorized Representative Signature
(Required)
Signature Date
(Required)
MM slash DD slash YYYY
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