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 baby's sleep?
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Please describe exactly what you are experiencing.
What are your sleep goals for your baby?
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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 baby 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 baby'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 their been any health issues or concerns?
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If so, please briefly describe them.
Is your baby on any medication?
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Did your baby have colic?
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No
Yes
Have you spoken to your doctor about your baby's sleep difficulties?
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Yes
No
Has your baby gone through any developmental milestones recently?
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i.e. smiling, tracking? with their eyes, rolling over
Tell me a bit about your baby's personality.
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Is your baby breastfeeding and/or bottle feeding? If so, what is the feeding schedule?
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How frequently does your baby eat?
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Has your baby ever been treated for a tongue tie?
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No
Yes
Does your baby snore?
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No
Yes
Does your baby use a pacifier? When do they use it?
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Does your baby use a swing, rock & play or bouncer? When do they use them?
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Where does your baby 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 baby sleeps in your room, when do you intend to move them to their own room?
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What does your baby 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 baby have a special stuffed animal that they sleep with?
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What signals do you notice your baby gives when he/she is tired?
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What is the longest stretch of sleep your baby gives you in a day?
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What time does your baby 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 baby take in a day?
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0 - napping just doesn't happen
1
2
3
4
5
6
How do you settle your baby to sleep for naps?
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What time do you start getting your baby ready for bed?
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What do you do with your baby when getting them ready for bed?
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i.e. bath, massage, brush teeth, sing songs, stories, games
How do you settle your baby to sleep at bedtime?
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What time does your baby actually fall asleep for the night?
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On average, how many times does your baby 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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