Your Name
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Email Address
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Phone
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(###)
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####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your biggest concern regarding your child's sleep?
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Please describe exactly what you are experiencing.
What are your sleep goals for your child?
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What are both parents' names?
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What is the occupation of both mom and dad? What is the work schedule?
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Tell me a bit about your parenting style.
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Does your child have any siblings? If so, what are their ages?
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Briefly describe your family's daily routine.
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i.e. time the family wakes, do you go for regular walks, meals, evening rituals, what time does the household go to bed?
Do you have any regular out of house commitments?
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i.e. pre-school, mommy classes, swimming lessons, etc. If so, please list when you leave the house and approximately when you return.
Does mom suffer from any postpartum depression or anxiety? If yes, is treatment being sought?
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Is everyone in your child's life on board with this process and changing your baby's sleep habits?
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Child's Name:
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Child's Age:
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Week's of Gestation:
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Birth Weight:
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Weight Now:
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Have there been any health/behavioural issues or concerns?
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If so, please briefly describe them.
Is your child on any medication?
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Did your child have colic?
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No
Yes
Have you spoken to your doctor about your child's sleep difficulties?
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Yes
No
Has your child gone through any developmental milestones recently?
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i.e. rolling over, standing, crawling, walking, talking
Tell me a bit about your child's personality.
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How does your child communicate?
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Is your child breastfeeding and/or bottle feeding? If so, what is the feeding schedule?
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How frequently does your child eat?
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Has your child ever been treated for a tongue tie?
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No
Yes
Does your child snore?
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No
Yes
Does your child use a pacifier? When do they use it?
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Does your child use a swing, rock & play or bouncer? When do they use them?
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Does your child watch TV or a Tablet? If yes, when and how much?
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Where does your child sleep?
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i.e. crib, bassinet, hammock, swing, family bed AND are they in their own room or are you room sharing
If your child sleeps in your room, when do you intend to move them to their own room?
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What does your child sleep in?
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i.e. swaddle, sleeper, onesie, sleep sack, etc.
On a scale of 1-10, with 10 being darkest, how dark would you describe your child's sleeping environment?
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Does your child have a special stuffed animal that they sleep with?
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Was there a time when your child slept well and then things changed?
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If so, please describe what happened at this time.
What signals do you notice your child gives when he/she is tired?
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What is the longest stretch of sleep your child gives you in a day?
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What time does your child wake to start his/her day?
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What happens at this time?
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Are they given a bottle, breastfeed? Where do you take them in your home?
On average, how many naps does your child take in a day?
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0 - napping just doesn't happen
1
2
3
4
5
6
Nap 1: What time of day does this nap usually occur? Where does it take place? How do you settle your child to sleep for this nap? How long does this nap last?
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Nap 2: What time of day does this nap usually occur? Where does it take place? How do you settle your child to sleep for this nap? How long does this nap last?
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Nap 3 & Nap 4 & Nap 5: Are there more naps that occur during the day? If so, tell me about them.
What time do you start getting your child ready for bed?
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What do you do with your child when getting them ready for bed?
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i.e. bath, massage, brush teeth, sing songs, stories, games
What time does your child actually fall asleep for the night?
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How does your child fall asleep at this time?
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On average, how many times does your child wake at night?
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1
2
3
4
5
I've lost count
What happens during the night wakings?
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Have you read any books about infant sleep, and have you tried any suggestions from these books in the past?
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Is there anything else you would like to share with me that you think I should know before we meet?
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Who do I have to thank for this referral? Where did you hear of wink blink & nod Sleep Solutions?
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Why did you decide to work with Dani at wink blink & nod instead of another sleep consultant?
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