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. 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. Who is Your Child’s Pediatrician?
6. What time does your child wake-up to start his/her day?
7. Your child is?Exclusively breastfed Formula fed Mixed fed (both: breast and formula milk) Eats solids + has breast milk Eats solids + has formula Eats solids+ has both, breast and formula Eats solids + has cow’s milk Eats solids only
8. How does your child start the day? Is he/she given a bottle, breast, solids, etc.?
9. Where does your baby sleep (crib, mom’s bed, mattress on floor, toddler’s bed) and does he/she share a room with anyone?
10. 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?
11. Do you keep the night light on once your baby is sleeping?
12. What signals do you notice your child gives when he/she is tired?
13. What time of the day does the first nap usually occur and where does it take place?
14. How do you get your child to sleep for his/her first nap?
15. What time of the 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 and a fourth nap during the day or early evening? What time does this happen?
19. How does your child fall asleep for those 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? (Example: bath, brush teeth, read stories, sing a song, feed)
22. What time does your child fall asleep at bedtime?
23. How does your child fall asleep at bedtime?
24. What happens during the night? (Best and worst-case scenario)
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? If yes, specify.
27. Is your child using a pacifier?
28. Does your child sleep at the same place most of the time?
29. Is your child spending any time watching TV, IPAD or smartphone? (Any electronics). If yes, for how many hours during a day?
30. Does your child sleep at the same place most of the time? (Naps and bedtime)
31. Is everyone in the family committed to seeing your child sleep well and on his/her own? 32. Have you worked with any sleep consultant previously? If yes, please provide her name. 33. Have you read any books about babies’ sleep, and have you tried any suggestions from these books? 34. Was there a time when your child slept well and were there any prominent changes in his/her sleep? 35. What are your sleep goals that you would like to accomplish by working together? 36. Why would you like to achieve this? 37. How are you feeling? What is the most common emotion that you feel? 38. How are your little’s current sleep patterns affecting your and your family’s life? 39. How do you envision your life if your child’s sleep patterns were to change for the better? 40. Is there anything else that you would like to share with me? 41. How did you hear about King of Sleep Services? 42. If a friend/colleague recommended King of Sleep Services to you, could you please let us know his/her name?
