Name: _____________________________________________________ Date of Birth: __________________________

Age: ____________________________________ Grade Level: ________________________________________

Father's Name: __________________________________ Mother's Maiden name: _____________________________

Questionnaire filled out by: _______________________________________________ Date: ______________________

Family information (any special aspects): ________________________________________________________________

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Pregnancy/Birth: ___________________________________________________________________________________

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Breast feeding: ____________________________________________________________________________________

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Child walked (give age) : ____________________

Toilet trained : ____________________

Bottle-fed until : ____________________

First words : ____________________

Phrases : ____________________

Complete language use : ____________________

Speech problems : ____________________

Feeding habits : ____________________

Significant events in child's life (moves, illnesses, etc.): _____________________________________________________

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Activities/Hobbies: __________________________________________________________________________________

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Previous schooling: _________________________________________________________________________________

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How long has your child lived in Costa Rica? _____________________________________________________________

How has the family adjusted to Costa Rica? _____________________________________________________________

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What is the expected length of your stay in Costa Rica? ____________________________________________________

Country Day School