Educational Support Enrollment Forms Health History

Educational Support with Ms. Marjorie

A Wholistic Approach to Strengthen the Foundations of Behavior and Learning

Please use these enrollment forms to fill out and submit online. Thank you for taking the time to answer these questions thoughtfully. Your input is essential to helping me get to know your child. ~ Marjorie

Enrollment Forms / Part 2: Health History

* Indicates required field

Child's Name *

First

Last

Child's Date of Birth *

What do you see as your child’s unique strengths and gifts? *

What are your main concerns about your child at this time? *

What are your biggest hopes for your child? *

Please describe the pregnancy. Were there any stressful situations? *

Describe the labor and delivery including setting, duration, family members involved, attendants, interventions such as medication, inducers, forceps, etc., cord around neck, special joys and feelings, etc. *

Approximate weight at birth *

Describe breastfeeding or bottle feeding and age weaned *

Describe the first few weeks of your child’s life *

At what age did your child: Belly Crawl *

At what age did your child: Sit *

At what age did your child: Hands/Knees Crawl *

At what age did your child: Walk *

Regarding crawling, sitting, walking: Was there anything unusual about the way your child did any of these *

Did your child spend time in a walker or upright seat (not including high chair) *

If your child did not crawl, how did he/she get around, pre-walking? *

At what age did your child speak their first words? *

At what age did your child speak in sentences? *

At what age did your child first use the word “I” for himself/herself? *

Was, or is, your child incontinent at night? *

Did your child have any habits such as thumb/finger sucking, hair twisting, nail biting, sucking on clothes, or a pacifier? Do any of these habits continue? *

Please describe any significant events during your child’s first seven years of life *

PLEASE COMMENT ON THE FOLLOWING AREAS *

Ability to care for personal space and belongings *

Ability to express feelings *

Was, or is, your child incontinent at night? *

Your child’s likes and dislikes *

What tends to make your child stressed? *

What makes your child relaxed and contented? *

Does your child help out with family chores? What kinds of chores are they helping with? *

On average, how much screen time does your child have (per week)? *

Breathing (stuffy nose, mouth breather, holds breath at times?) Is there any tendency towards asthma? *

Sleeping *

Eating preferences in general *

Eating preferences / types of fats eaten *

Eating preferences / types of proteins eaten *

Eating preferences / types of carbohydrates eaten *

Eating preferences / types of probiotics or fermented foods eaten *

MEDICAL/DENTAL HISTORY *

Approximate age at first tooth loss *

Number of teeth out at this time? *

Has your child had ear infections? *

Has your child used prescribed medications such as antibiotics? *

Has your child received the routine childhood immunizations? Describe any reactions to the immunizations *

Has your child had a fever? *

Any illnesses such as chicken pox? *

Please describe any serious injuries, accidents or surgical operations *

What childhood bumps and falls have occurred, especially to the head (at home, playground, etc.) *

Please describe any other concerns or comments regarding your child *

RELEVANT INFORMATION ABOUT SCHOOL LIFE *

Learning style (i.e. sequential versus big picture, auditory, visual, or kinesthetic?) How does your child learn most easily? *

Ability to pay attention *

Social interactions *

Organizational skills *

What does your child like most about school? *

Does your child have concerns about school? *

In school: What are your child’s strengths? What are your child’s challenges? *

Once you have completed filling in the form please click/tab the SUBMIT button below. The information will be submitted and you will be directed back to the Enrollment Forms page. Please continue with Enrollment Forms / Part 3.

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