Children Sleep Intake Questionnaire

ABOUT YOU & YOUR FAMILY

First Name*

Last Name*

Email*

Phone*

Child's Name*

Child's Date of Birth*

Spouse's Name*

Spouse Email*

Spouse Phone Number*

Home Address*

Name and age of siblings*

Name of caregiver / nanny / 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)*

If your child goes to daycare / extended school days, what is their policy on sleep? Would they be open to following your guidelines on sleep?*

Are you going on a trip / holiday soon?*

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

Yes

HELP WITH SLEEP

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

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?*

Have you ever worked with another sleep consultant?*

Yes

If yes, please give me some background*

How did you hear about Sleep Solutions Ltd*

Internet

Social Media

Referral

If a friend referred you, please let me know their name so I can thank them*

HOW YOUR CHILD FALLS ASLEEP

Does your child rely on the following to fall asleep (choose as many as necessary)

Feeding (Breast)

Feeding (Bottle)

Rocking, bouncing, carrying (motion)

Rubbing, patting, stroking, (touch)

Baby carrier, car seat, stroller, buggy, pram

Adult sitting in the room / laying next to

With a pacifier / dummy

None of the above

If none of the above, please provide details

My child uses a pacifier at bedtime / nap time*

Yes

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

Yes

What signals do you notice your child give when he/she is tired*

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

What does your child wear to bed?*

Does your child still sleep in a sleeping bag?*

Yes

If yes, please provide the type and tog*

Does your child sleep under a duvet / blanket?*

Yes

SLEEP ENVIRONMENT

Our child:*

Co-sleeps in the same room as parents

Bed shares with parents

Sleeps in a crib in own bedroom

Sleeps in a big bed in own bedroom

Shares a room with a sibling

Shares a room with another adult (grandparent / nanny / helper)

Other

Child's sleep environment has:*

Blackout curtains

White noise

Aircon / fan

Night light

Toys / bumpers / pillows / bolsters in the bed

Baby monitor - video and sound

Baby monitor - sound only

None of the above

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

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

DAYTIME ROUTINE

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

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

What is the latest your child needs to be awake by to get to school on time?*

Please outline a normal day for your child, including wake up time, routines, meal times, activities, etc.*

Does your child still nap during the day?*

Yes

If yes, at what time do the nap and for how long?*

How do you help your child fall asleep for their daytime nap?*

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

How often does your child sleep in the car / school bus / stroller?*

How much screen time does your child get during the day?*

What time of day does your child have screen time (screens of any kind)?*

What other activities / sports does your child participate in during the week?*

NIGHT TIME ROUTINE

What time is your child's bedtime?*

What time is your desired bedtime?*

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

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

On average, how often does your child wake during the night? (Include timings and length of time it takes to get back to sleep)*

What do you do to help your child go back to sleep in the night?*

Does your child have a lovey / comfort item(s) they take to bed with them?*

How would you rate your child's eating habits? (Picky eater / healthy appetite / only eats the same 5 things...)*

What would an average day of food consumption look like? (Meals, snacks and treats)*

How much juice / milk does your child consume each day?*

What time is dinner usually?*

MEDICAL HISTORY / DEVELOPMENT / BEHAVIOURAL CONSIDERATIONS

Are there any health concerns for your child?*

Does your child snore or breathe through their mouth while they are sleeping?*

Is your child on any medication?*

Yes

If yes, please provide details*

Does your child have any allergies or food intolerances?*

Has your child been sick in the last year?*

Do you have any behavioural concerns with your child?*

Are there any concerns with your child's communication skills?*

How does your child respond to instruction or discipline from you, and or from others?*

How does your child handle transitions from one activity to another?*

How does your child respond to stress?*

What would you say your child's currency / pain points are? Things other than TV / devices / food - that could be used as leverage in behaviour modification

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

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*

How do you think not sleeping well is affecting your child?*

Is your child's sleep affecting you and your partner?*

Tell me what you miss the most about not sleeping well*

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

Please verify your request*