Kindergarten Health History Template - Multicare Associates Page 3
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4D. As part of our pre-school medical examination, we need information about your child’s behavior,
development, emotions, moods or physical or psychological factors that might influence his response
to school life and requirements.
1. Is your child more active than average?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
2. Is he quiet and less active than average? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
3. Does he tire easily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
4. Does he still wet the bed at night? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
5. Does he have any problems with speech?. . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
6. Does he seem to have trouble hearing you?. . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
7. Does he wake up earlier than the rest of the family? . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
8. Is he awkward, clumsy or poorly coordinated?. . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
9. Does he seem slow to you in any way? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
10. Does he still need a nap? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
11. Does he frequently misunderstand what you tell or ask him? . . . . . . . . . . . .
YES
NO
SOMETIMES
12. Do others pick on him a lot?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
13. Is he upset when separated from his mother? . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
14. Does he have a lot of trouble with his brothers or sisters? . . . . . . . . . . . . .
YES
NO
SOMETIMES
15. Do you think he is unusually selfish? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
16. Do you fear that he may be too babyish or immature? . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
17. Is he timid with other children?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
18. Is he easily frustrated and irritable?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
19. Does he get angry easily and often? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
20. Do you think he is overly sensitive? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
21. Does he prefer to play alone or with much younger children? . . . . . . . . . . .
YES
NO
SOMETIMES
22. Does he cry easily?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
23. Do you think he is nervous, highstrung, or excitable? . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
24. Does he want to be the center of attention all the time? . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
25. Does he have nightmares or frightening dreams? . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
26. Does he wake at night often? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
27. Does he give up on things if he cannot do them well?. . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
28. Do you think of him as shy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
29 Is he quite stubborn? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
30. Does he soil his underclothes sometimes? . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
31. Does he seem unusually fearless or reckless?. . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
32. Does he bite his fingernails? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
33. Does he put off things like going to bed? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
34. Is he a finicky eater? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
35. Does he dawdle over breakfast or dressing himself? . . . . . . . . . . . . . . . . . . .
YES
NO
SOMETIMES
36. What is his greatest fear?______________________________________________________________________
37. What is your greatest concern about your child?___________________________________________________
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