Your Name (Parents Name)?
Your Contact Number?
How did you hear about me?
Answer the following Questions!
1. How old is your child and what is his/her weight?
2. Was your child premature, if YES! how many weeks your child was when he/she was born?
3. Have there been any health issues or concerns (Colic, Reflux, Snoring, or Heavy Mouth Breathing etc.)
4. Is your child on any medication?
5. Have you spoken to your doctor about your child’s sleep difficulties?
6. What time does your child wake-up to start his/her day?
7. How does your child starts the day? is he/she given a bottle, breast feed, solid etc.?
8. Where does your baby sleep and does he/she share a room with anyone?
9. On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime, and through the night?
10. Do you keep the night light on once your baby is sleeping?
11. What signals do you notice your child gives when he/she is tired?
12. What time of day does the first nap usually occur and where does it take place?
13. How do you get your child to sleep for his/her first nap?. What do you do before your child starts the nap?
14. How long does this nap last?
15. What time of day does the second nap occur?
16. How does your child fall asleep for this nap?
17. How long does this nap last?
18. Is there a third or fourth nap during the day or early evening? How long do they last?
19. How does your child fall asleep for these naps?
20. What time do you start getting your son/daughter ready for night sleep?
21. What do you do with your child when getting them ready for bed? (For example, bath, brush teeth, sing songs, read stories, play a game, etc.)
22. What time does your child fall asleep at bedtime?
23. How does your child fall asleep at the time?
24. What happens during the night? (Best AND worst-case scenarios.)
25. Do you feed your child during the night? How many times?
26. Does your child get any sweet drinks or sweet snacks before he goes to bed?
27. Does your child sleep at the same place most of the time? (naps and bedtime)
28. Have you read any books about babies sleep, and have you tried any suggestions from these books in the past?
29. Was there a time when your child slept well and were there any prominent changes in his sleep?
30. Does your child use a pacifier when he/she sleeps?
31. What would you like to see happening? What are your main goals?
32. Is there anything else you would like to share with me that you think I should know before we meet?