CDL Family Data Sheet

Child Development Laboratory

All information on this form is kept confidential and is available only to the full-time staff at the Child Development Laboratory. The information is added to a database and used under strict protocols to facilitate the teaching and research functions of the CDL program. All identifiers are removed before adding this information to the database to insure confidentiality. Codes rather than names are used when releasing this information for teaching and research activities.
Please complete the following CDL Family Data Sheet.

CDL Family Data Sheet

CDL Family Data Sheet

Child's Name & Preferred Name:

Date of Birth: (mm-dd-yyyy)

Date child first entered CDL:

Language spoken at home:

Does child speak English?

Does child understand English?

Ethnic background

Allergies:

Family's religion:

Are there any food or activity restrictions for your child due to religious beliefs?

Describe mealtime at home (where/when/with whom/etc.):

Any particular food dislikes or aversions:

Any prominent fears:

When, how long, where, with what, or whom does your child sleep/nap?

Child's weight at birth:

Length of pregnancy (premature/full term, number of months):

Were there any complications with the pregnancy or birth?

List any serious illness or hospitalization:

Any handicaps or abnormalities:

Does your child experience any chronic illnesses (ear infections, upper respiratory infections, tonsillitis, etc.)?

Any regular medications? (When given: By whom: Medicine Doctor prescribed?)

Was child adopted?

Status of parents/guardians: (Please select one)

If separated or divorced, who is the custodial parent/guardian?

Any restrictions on non-custodial parent's visits or participation at school?

How does your child react to separation and being cared for by others?

When does your child typically cry?

Is your child comforted easily?

How do you comfort your child?

Bowel control:

Bladder control:

Does child state need for bowel movement?

Does child state need for urination?

Comments on toileting needs/habits: