Beautiful Baby Sleep Intake Form

Introduction:

First and Last Names of Parents:
Email:
Phone number:
Address:
children's names:
children's dates of birth:
1.Were your child or children born prior to 37 weeks of pregnancy and if so, what was the period of gestation? What was your children's original expected due date?
2.What developmental milestones have your child or children reached? i.e - are your child or children able to roll over, sit up, stand, walk?
3.What are your sleep goals for your child or children?
4.Are you the primary caregiver for your child or children? Please list any other caregivers and describe their involvement in caring for your child or children.

Schedule:

5.What time do your child or children wake up in the morning?
6.What time do you put your child or children to bed?
7.Do your child or children nap during the day? How often, for how long and at what times?
8.Describe your child or children's bedtime routine, if any.
9.How long does it take for your child or children to fall asleep?
10.How often do your child or children wake up during the night and for how long? How do you respond?
11.Do you use any aids to help your child or children sleep? i.e. Soother, sound machine, mobile, swaddling, singing, bouncing, rocking, etc.

Sleep Environment:

12.Do your child or children bedshare (sleep in your bed), co-sleep (sleep in a separate crib in your room), or sleep in their own room?
Briefly describe your child or children's nighttime sleep environment by answering the following:
13.Does the room tend to get too hot or too cold?
14.On a scale of 1 to 10, how dark is the room? 1 being daylight bright and 10 being pitch black.
15.On a scale of 1 to 10, how noisy is the room? 1 being noisy with regular daytime noise and 10 being completely silent.
16.Do your child or children sleep in a sleep sack? What do they wear for naps and bedtime?
17.Please indicate if the sleep environment is different for naps. If yes, where do your child or children nap?
18.Do you use a visual baby monitor?

Experience with Sleep Training:

19.Have you tried sleep training in the past? If yes, please describe the method(s) you used and explain what was or wasn’t successful.
20.Are there any sleep training methods you do or do not want to use?

Personal and Medical History:

21.How would you describe your child or children's mood during the day on average?
22.Who is your child or children's pediatrician or family doctor?
23.Do your child or children or have your child or children previously had any diagnosed medical conditions or concerns? If yes, please describe.
24.Are your child or children being actively monitored for any medical conditions or concerns? If yes, please describe.