Your Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Child's Name First Name Last Name Childs Date of Birth MM DD YYYY Marital Status Single Partnered Married Divorced Widowed separated Partners name if applicable First Name Last Name Names and ages of siblings or other children living with you Was your baby born on their due date? If not, how many days early or late? 's Birth Weight Baby's Current Weight Baby's Height Date of last developmental visit MM DD YYYY Does your baby use a dummy? If so, do they need it to fall asleep and do they wake if it comes out? How much sunlight is your baby exposed to on a daily basis? Up till what hour at night is your baby exposed to artificial light? Is your baby breastfeeding, infant formula feeding or both? Is your baby eating solids? Describe their diet including quantities If breastfeeding, briefly describe the breastfeeding mother’s diet including amount of caffeine: Any known allergies? Asthma? Medical issues? (Including colic/reflux) If so, is your baby on any medication? Does your baby snore, breathe with their mouth open, or sweat during their sleep? Does your baby wake up from obvious nightmares? Do they suffer from night terrors? Describe your baby’s temperament: easy going/chilled out slow to warm up difficult to soothe/entertain mixed What is your baby’s usual activity level? How adaptable/resilient is your baby? How distractible is your baby? anything else we should be aware of or give consideration to when making a sleep plan for your baby? What are your expectations of sleep training/support? Is there anything you’ve are afraid of? What is your goal/outcome and how motivated are you to achieve this? Is stress a major problem for you? yes no Do you feel depressed? yes no Do you panic when you're stressed? yes no Do you have problems with eating or your appetite? yes no Do you cry frequently? yes no Do you have problems with eating or your appetite? yes no Do you have trouble sleeping? (aside from baby’s disruptions) yes no Have you ever been to a counsellor? yes no Do you have support from a partner / family member / friend on a regular basis? yes no Are you on any medication? yes no If you are on medication? What for? How long: Thank you! Sleep Questionnaire