Your Name (Parents Name)?
Your E-mail?
Your Contact Number? How did you hear about me?
What’s Your child’s Full Name?
What’s Your Child’s Date of Birth?
Answer the following Questions!
1. What’s Your Child’s Weight?
2. Have there been any health issues or concerns (Colic, Snoring, Heavy Mouth Breathing, Reflux)
3. Is your child on any medication? If yes, please provide the medication names your child is taking.
4. Who is Your Child’s Pediatrician? Please mention the hospital.
5. Have you spoken to your child’s 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 start the day? What is the first thing that you do once he wakes up in the morning?
8. Where does your child sleep (crib, mom’s bed, mattress on floor, toddler’s bed) 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 during the night?
10. Do you keep the night light on once your child is sleeping?
11. What would an average day of food consumption look like? Breakfast, snacks, lunch, dinner, treats?
12. What time is dinner?
13. Does your child have any snacks right before the bed? If so, what?
14. Are there any developmental delays, behavioral issues or concerns about your child?
15. How does your child respond to instructions or disciplines from you, and from others?
16. Where and when does your child watch TV or play on any other sorts of electronic devices?
17. How many hours a day does your child spend watching TV, Ipad or any other sorts of electronic devices?
18. Is your child still taking a nap during the day?
19. How long is this nap and at what time does it happen?
20. Where does this nap take place?
21. How does he/she fall asleep for this nap?
22. What time do you start getting your son/daughter ready for night sleep?
23. What do you do with your child when getting them ready for bed? (Example: bath, brush teeth, read stories, sing a song, feed)
24. What time does your child fall asleep at bedtime?
25. Are there any schedule challenges with getting your child to bed on time?
26. How does your child fall asleep at bedtime?
27. What happens during the night? (Best and worst-case scenario)
28. Do you feed your child during the night? How many times?
29. Is your child using a pacifier?
30. Does your child sleep at the same place most of the time? (Naps and bedtime)
31. Was there a time when your child slept well and were there any prominent changes in his/her sleep?
32. What are the most frustrating or difficult issues for you around your child’s current sleep habits?
33. Has your family experienced any major life changes or traumas that could be affecting your child? 34. Is there a family history of depression or anxiety disorders? 35. Is everyone in the family committed to seeing your child sleep well and on his/her own? 36. Have you worked with any sleep consultant previously? If yes, please provide her name. 37. Have you read any books about children sleep, and have you tried any suggestions from these books? 38. What are your sleep goals that you would like to accomplish by working together? 39. Why would you like to achieve this? 40. How are you feeling? What is the most common emotion that you feel those days? 41. How are your child’s current sleep patterns affecting your and your family’s life? 42. How do you envision your life if your child’s sleep patterns were to change for the better? 43. Is there anything else that you would like to share with me? 44. How did you hear about King of Sleep Services? 45. If a friend/colleague recommended King of Sleep to you, could you please let us know his/her name? 46. Is there anything else you’d like to share with me that you think I should know?
