Baby Sleep Intake Questionnaire

ABOUT YOUR CHILD
Please give details of baby's birth *
Do you currently have, or will you be hosting house guests during sleep training?*
How did you hear about Sleep Solutions, LTD*
HELP WITH SLEEP
FEEDING
Milk feeds - how do you feed your baby?*
Do you*
Has your baby started solids?*
My approach to feeding is:*
HOW YOUR BABY LIKES TO FALL ASLEEP
Does your baby rely on the following to fall asleep (choose as many as necessary):*
My baby uses a pacifier at bedtime and/or nap time*
My baby uses a pacifier at other times during the day/night*
BABY'S SLEEP ENVIRONMENT
Our baby:*
Baby's sleep environment has:*
Using the Bedroom Darkness Scale - How dark is your baby's room during the daytime, when the curtains and door is closed?*
Does your baby sleep in a sleeping bag?*
Please take a video of %CHILDS_NAME% 's room and send it to Alison. Layout of the room - where the crib is in relation to the windows, door and a/c unit.*
DAYTIME ROUTINE
NIGHT TIME ROUTINE
FAMILY ENVIRONMENT
MEDICAL HISTORY / DEVELOPMENTAL MILESTONES / GROWTH
Is your child on any medication?*
Which of the following developmental milestones has your baby reached?*
PERSONALITY & INTERESTS
ANY ADDITIONAL COMMENTS