Baby Sleep Intake Questionnaire

First Name*

Last Name*

Phone*

Email*

Spouse's Name*

Spouse Email*

Spouse Phone Number*

Home Address*

ABOUT YOUR CHILD

Child's Name*

Please give details of baby's birth *

Natural

C-Section

Premature

Traumatic

How much did baby weigh at birth?*

How much does baby weigh now?*

Do you currently have, or will you be hosting house guests during sleep training?*

Yes

No

Are you going on a trip / holiday soon?*

How did you hear about Sleep Solutions, LTD*

Internet

Social Media

Referral from your friend

Other

If referred by a friend, please share their name?*

HELP WITH SLEEP

Have you read any books on parenting / sleep training? If so please provide details*

Have you tried any methods from any sleep training book / the internet / recommended by friends? If so please provide the method and success / failures.*

Is there anything that you have read that you don't feel comfortable with?*

FEEDING

Milk feeds - how do you feed your baby?*

Breast Fed

Breast Fed {Expressed}

Bottle Fed {Formula}

Mix Feed {Breast milk and formula}

No Milk Feed

Do you*

Feed on Demand

Stick to a Schedule

Depends on the Day

Please provide the times of milk feeds during the day.*

Please provide the times of milk feeds during the night*

How long on each breast? Or how many ml's per feed, if bottle feeding?*

What is the total amount of milk your baby is consuming in 24 hours?*

Has your baby started solids?*

Yes

No

My approach to feeding is:*

Puree

Baby Led Weaning

Combination of both

If your child is on solids, please give me a broad overview of his feeding habits (timing and type of foods, quantities, etc)*

Any other comments around your baby's feeding?*

HOW YOUR BABY LIKES TO FALL ASLEEP

Does your baby rely on the following to fall asleep (choose as many as necessary):*

Feeding (breast)

Feeding (bottle)

Rocking, bouncing, carrying (motion)

Baby carrier, car seat, stroller, pram

With a pacifier / dummy

Dream feed

My baby uses a pacifier at bedtime and/or nap time*

Yes

No

My baby uses a pacifier at other times during the day/night*

Yes

No

What signals do you notice your baby gives when he/she is tired?*

Any other comments regarding how I help my baby get to sleep*

BABY'S SLEEP ENVIRONMENT

Our baby:*

Co-sleeps in the same room as parents

Bed shares with parents

Sleeps in a cot in own bedroom

Sleeps in a cot in room shared with a sibling

Sleeps in the same room as another adult (grandparent / caregiver)

Using the Bedroom Darkness Scale - How dark is your baby's room during the daytime, when the curtains and door is closed?*

1

2

3

4

5

Please share any other details with regard to your baby's sleep environment*

If you use aircon in your baby's room, what temperature is it set on?*

What does your baby wear to bed for naps?*

What does your baby wear to bed for night time?*

Does your baby sleep in a sleeping bag?*

Yes

No

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.*

Done

Will submit later

DAYTIME ROUTINE

What time does your baby wake up to start the day?*

What is the ideal time you would like your baby to start their day?*

Please describe your baby's typical daytime routine*

On average, how much awake time does your baby have between each nap?*

How do you help your baby go to sleep at naptime?*

On average, how long does your baby sleep for each nap?*

Where does your baby sleep for naps during the day?*

NIGHT TIME ROUTINE

Where does your baby sleep at night time?*

What time is your baby's bedtime?*

Please give details (including timings) of your baby's bedtime routine?*

How do you help your baby go to sleep at bedtime?*

n average, how often does your baby wake during the night? (Include timings if you know of any consistent night wakings)*

What do you do to help baby go back to sleep?*

What is your desired bedtime for your baby?*

FAMILY ENVIRONMENT

Who lives in the family home (both parents, siblings, extended family, helper)?*

Who is the primary carer?*

If both parents work, please explain childcare arrangements (ie Helper at home, infant care, looked after by a relative in their home etc)*

MEDICAL HISTORY / DEVELOPMENTAL MILESTONES / GROWTH

Did your baby have colic or reflux? If so please provide details of treatment*

Has your baby been sick since birth / in the last year? If so, please provide details*

Is your child on any medication?*

Yes

No

Does your baby have any teeth? If so please provide details*

PERSONALITY & INTERESTS

Tell me about your child's personality. Do they have strong likes or dislikes*

Does your baby engage in any activities such as swimming lessons, playgroups, other classes etc? If yes, please provide timings / proposed timings and frequency during the week.*

Does your child have a particular item, such as a soft toy or comforter that they are particularly attached to?*

ANY ADDITIONAL COMMENTS

What are your expectations with regard to sleep training?*

Please use this space to give any additional information you feel might be relevant to your little one's sleep issues*

What date would you like to get started?*

Just imagine... Making any kind of change can be hard. It's important you have a clear understanding of all the reasons why you need to make this necessary change to your baby's sleep habits. It's going to make sticking to the plan all the easier. Th*

Some people don't notice any issues with their baby, she's as happy as ever, while others notice some symptoms in their baby that clearly shows that baby's not been sleeping well either. List all the ways in which you feel poor sleep is affecting you*

In what ways do you think the situation is affecting you and your partner?*

Tell me one thing you miss the most about not sleeping well?*

What's the first thing you are going to do when your baby is in bed and asleep at 7:00pm?*

What's a little gift you can give yourself once you've taught your baby to sleep well and sleep all night?*

Please verify your request*