Children Sleep Intake Questionnaire

ABOUT YOU & YOUR FAMILY
Do you currently have, or will you be hosting house guests during sleep training?*
HELP WITH SLEEP
Have you ever worked with another sleep consultant?*
How did you hear about Sleep Solutions Ltd*
HOW YOUR CHILD FALLS ASLEEP
Does your child rely on the following to fall asleep (choose as many as necessary)
My child uses a pacifier at bedtime / nap time*
My child uses a pacifier at other times during the day / night*
Does your child still sleep in a sleeping bag?*
Does your child sleep under a duvet / blanket?*
SLEEP ENVIRONMENT
Our child:*
Child's sleep environment has:*
DAYTIME ROUTINE
Does your child still nap during the day?*
NIGHT TIME ROUTINE
MEDICAL HISTORY / DEVELOPMENT / BEHAVIOURAL CONSIDERATIONS
Is your child on any medication?*
ADDITIONAL COMMENTS