 Child's Name:
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Birth Date:
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Chronic Illnesses:
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Any Known Allergies? (Asthma, Hay Fever, Insect Bites, Medicines, Food, etc.)
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Are any medications given regularly?
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Child's favorite toys, activities, etc.:
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Favorite Foods:
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Briefly describe your child's behavior:
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What makes your child mad or upset?
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How does your child show feelings?
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What do you find is the best way of handling your child?
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Any special needs required
__________________________________________________
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Parent Signature Date
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