Questionnaire

Parents Name

First Name

Last Name

Email Address

Child's Name(s)

First Name

Last Name

Child's age (in weeks, months or years)

Was your child born prematurely?

Yes

If born prematurely, how many weeks?

Is your child at a healthy weight?

Yes

How is your child fed?

Bottle

Breast Fed

What is your child's current sleep environment?

Please include where they sleep, if you use black out curtains and/or white noise.

What is your child's current morning wake-up time?

Hour

Minute

Second

Does your child need to be awake at a specific time each morning? If so, what time?

Hour

Minute

Second

What is your child's current bed time?

Hour

Minute

Second

What is the ideal bedtime you have for your child?

Hour

Minute

Second

Have you implemented a bedtime routine? If so, please describe it.

What is your child's current nap schedule?

Provide time of day and average duration of naps

Are there any scheduling conflicts I should be aware of when giving recommended nap times?

How long does it take for your child to fall asleep?

Can your child fall asleep unassisted? If no, how do you get your child to fall asleep?

How many night wakings is your child having? How do you respond?

How many times is your child eating during the night?

How many night feedings do you wish to keep? If none, has your Pediatrician approved your child go 12 hours overnight without eating?

Does your child use a pacifier/swaddle/comfort blanket?

Have you received approval from your Pediatrician to move forward with sleep training?

Yes

Is your child in dayare outside of the home? If yes, how many days/week and please describe their sleep environment and schedule when there.

Please describe the issues you are currently facing with your child's sleep habits and include any methods you have used to attempt to correct them.

What are your sleep goals for your child?

Are there any sleep training methods that you agree or disagree with?

Are there any medical issues that I should be aware of?

How did you hear about me?

Please include any other information that you would like for me to know.