Admissions Questionnaire for the Well-Being Department

GRADE: PRE-NURSERY

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PN

The following questionnaire includes a series of questions about your child. We kindly ask you to answer sincerely. All information provided will remain confidential and will be used exclusively for the SPIS admissions process.

Please answer all questions to the best of your ability, even those that may not fully apply to your situation. If you have any questions, please consult the person in charge on the day of the evaluation.

Campus

Student's information

Date of birth

Parent's information

People the student lives with
Personas con las que vive el alumno(a) 2
Personas con las que vive el alumno(a) 3
Personas con las que vive el alumno(a) 4
Personas con las que vive el alumno(a) 5
Personas con las que vive el alumno(a) 6
Personas con las que vive el alumno(a) 7

Family relationships

Check the activities the child participates in with the family and their frequency.

Cine
Comidas
Viajes
Visitas
Deportes
Juegos
Televisión
Otros

Development History

Pregnancy and birth details of the child. Please describe if necessary.

At what age did the child do the following for the first time? Please indicate the number of months.

Has the child experienced any of the following situations? If yes, please describe.

Difficulty walking
Poor speech clarity
Feeding problems
Underweight or overweight issues
Colic
Sleeping problems
Excessive crying

Medical history

Illnesses or injuries the child has had. If yes, please describe.

Has the child been hospitalized?
Respiratory problems such as cold, chronic cough, asthma, sinusitis, or others.
Cardiovascular issues such as shortness of breath, dizziness, heart murmur, or others.
Gastrointestinal issues such as vomiting, diarrhea, constipation, stomach pain, or others.
Genitourinary issues such as frequent urination, pain while urinating, or others.
Musculoskeletal issues such as muscle weakness, unsteady gait, poor posture, or others.
Dermatological issues such as rashes, bruises, sores, skin itching, or others.
Neurological issues such as seizures, teeth grinding, speech problems, nail biting, nervous tics, rocking, head banging, thumb sucking, or others.
Allergic to medications and/or foods.
Hearing issues such as ear infections, hearing problems, or others.
Visual problems, use of glasses, or others.

Medical care

Friendships

Please indicate how the child interacts with other children by selecting what applies:

Hobbies and interests

Behavior and Temperament

Please indicate whether the child exhibits any of the following behaviors:

Adaptive Skills

Adaptive Skills