Sleep Questionnaire

I’d like to ask you to take a few minutes to answer some questions about your child’s sleep habits before we talk in person.

This will help me prepare for our meeting, and will let us make the best use of our time together.

There are quite a few questions, but almost all of them can be answered in just a sentence or two, so please don’t be intimidated! I’d rather you give more information then you think is needed

You can just answer the questions in the spaces provided, and then click the Submit button after entering the Captcha Code.

It would be great if you could have this back to me at least 2 days before our meeting!

Thanks, and the questions start below!

General Information:

* indicates required field

Email:*

Name of Father:

Name of Mother:

Name of Child:

Age of Child:

Child’s Pediatrician/Location:

How did you hear about Gift of Sleep Consulting?

Guiding families from sleep deprived to sleep revived.

Feeding (please answer all that are applicable):

1. Do you breastfeed, bottle feed or both?

2. How long on each breast, how many ounces per feed if bottle fed?

3. When do the feedings occur during the day?

4. When do the feedings occur during the night?

5. If your child is on solids yet, please give me a broad overview of his/her feeding habits (timing, type of foods, quantities, etc.):

Guiding families from sleep deprived to sleep revived.

  Daytime Routine:

1. Does your child have a nanny, babysitter or is enrolled in daycare?

2. Please describe a typical daytime routine in your child’s life:

3. What time does your child usually wake up and start the day?

4. If you have a baby (under 1 year of age) how long is he/she usually awake before sleeping again?

5. How many naps does your child have per day?

6. Where does your child sleep for naps?

7. How does your child fall asleep for naps?

8. How long does each nap usually last?

Guiding families from sleep deprived to sleep revived.

  Nighttime Routine:

1. What time does your child go to bed?

2. When does your child take a bath (daily, every other day, etc)?

3. Do you have a structured bedtime routine? Please describe.

4. Where does your child sleep at night?

5. How does your child fall asleep at bedtime?

6. How often does your child wake up during the night (please explain best and worst case scenarios)?

7. What do you do to get your child back to sleep during the night?

Guiding families from sleep deprived to sleep revived.

  Daily Occurrences:

1. Does your child use a pacifier? If so, when does he/she use it?

2. Does your child watch television on a daily basis? If yes, when and how much?

3. Does your child often fall asleep while breastfeeding or drinking from a bottle?

Guiding families from sleep deprived to sleep revived.

  Family Info:

1. If there are other children in the family, how are they sleeping? Do they have any challenges?

2. How many hours do both parents have each day to spend exclusively with the child?

3. If both parents work, at what times do they leave the child for the day and at what times do they return home?

Guiding families from sleep deprived to sleep revived.

  Medical:

1. Was your child premature?

2. Was your child diagnosed with any medical complications at birth?

3. Is your child under medical supervision for an illness at this time?

Guiding families from sleep deprived to sleep revived.

  Growth and Wellness:

1. What does your child currently weigh?

2. What was your child’s weight at birth?

3. If your child is under the age of 2, please tell me about his/her teeth and teething process.

4. Has your child reached any developmental milestones lately? (Ex: sitting, crawling, standing, walking etc.)

Guiding families from sleep deprived to sleep revived.

  Sleep Education:

1. What books have you read regarding baby sleep?

2. Have you tried any methods described in these books or recommended by family or friends?

3. Is there anything you have read that you are not comfortable with?

Guiding families from sleep deprived to sleep revived.

  Environmental Factors:

1. Does your child sleep in a crib or bed?

2. What does your child sleep in? Does your child sleep with a blanket?

3. Does your child have black out blinds in his/her room?

4. Does your child have toys in their bed?

5. Is there a mobile attached to crib?

6. Do you have a baby monitor and do you use it?

7. Do you use a night light in the room?

8. What is a consistent room temperature for your child’s room?

Guiding families from sleep deprived to sleep revived.

  Open Forum:

1. Why did you contact Gift of Sleep Consulting?

2. What are your expectations?

3. Is there anything additional you would like to share with us regarding your child (sleep or otherwise related)?

Guiding families from sleep deprived to sleep revived.

  Contact information:

Please provide an address so that we may keep in contact with you:

Guiding families from sleep deprived to sleep revived.

CAPTCHA Code:*