Sleep Questionnaire

The information gathered from the series of questions below will allow me to better prepare and support you during our time together. You will have an opportunity to describe your child’s sleep history, temperament, personality, daily routine, your parenting philosophy, and other pertinent information.

The more information you provide the better!

Your Name

First Name

Last Name

Child's Name

First Name

Last Name

Phone Number

Address

Child’s DOB

Please provide the exact age e.g. 5months, 2 weeks

Child’s Birth Weight

Child’s Current Weight

Date of last weigh in

Was your child premature, if yes what is child’s corrected age?

Does your child have any medical issues we should be aware of?

(reflux, sleep apnea allergies, etc.)

Does your child snore?

How would you best describe your child’s temperament / personality?

Sleep Environment

Where does your child sleep?

E.g. bassinet, co-sleeps, cot, same room, own room

Does your child have a pacifier / dummie?

What does your child sleep in?

E.g. sleeping bag - love to dream, ergo, swaddled, pj's, blankets

Does your child have a comforter / lovey?

Describe the sleep environment

E.g. mobile over cot, night light, humidifier

Rate the level of darkness in his/her room

1 being bright and sunny, and 5 being absolutely dark

Do you use white noise?

If so – for all sleeps? Only daytime? Only nighttime? In transit - pram?

Milk/Food

Breastfed or Formula or mix feeding?

If formula fed advise volume ie: 150ml x 3 times a day

Solid food – including volume

Breakfast / Lunch / Dinner / Snacks

Does your child wake for feedings?

If yes, how many times? What time do these waking’s typically occur?

Sleep

How many naps does your child have a day?

What times and duration does your child nap?

E.g. 9am | 45min / 12pm | 2hr

How do you settle your child for daytime nap?

E.g. rocking, patting, singing

What time do they wake in the morning?

What time is bedtime?

If child wakes through the night how to you settle them back to sleep?

Does your child attend childcare or in the care of someone else through the day?

If so, how do they get child to sleep

Support

Please describe in detail what challenges you are experiencing with your baby’s sleep and how you have managed thus far

Describe your parenting style.

Do you go with the flow? Prefer a strict routine? Routine with flexibility

What sleep training methods align with your parenting philosophy?

Gentle settling approach, controlled crying or somewhere in between

Do you have any other children? If so, what are their commitments?

E.g. school drop off, soccer on Saturday morning

Do you want a routine that outlines - age appropriate awake times, nap times, bed time or would you prefer flexible solutions depending on what time your child wakes or perhaps just setting technique outlined

Do you co-parent? If so, are they on board with obtaining sleep support and committed to the process?

What support Package are you interested in?

Package One | 45min - 1hr Single Phone Consult

Package Two | 1hr Phone Consult + 2 weeks Support

Package Three | 2hr Home Visit + 2 weeks Support

Sleep Questionnaire

Navigate