Infant & Young Toddler Sleep Questionnaire

I’d like to ask you to take a few minutes to answer some questions about your child’s sleep habits and more before we have our consultation. This will help me prepare for our meeting and will let us make the best use of our time together. Please note, that some questions may not apply to your family and if that is the case, feel free to skip over those.

Please include as much information as possible; this will help me learn about your child and family and all the factors that could affect sleep. Please return this as quickly as possible so I can begin working on your child’s sleep program.

Thank you for putting your trust in me to help your child to develop healthy sleep habits.

Medical Questions
Milestone Assessment - Please check off the skills your child has MASTERED:
Dietary Questions
Sleep Questions
Where does your child sleep?
Daily Childcare
Is your child cared for by someone other than you?
Does you child use any of the following?
Sleep Props_Infant
Night Wakings
Scheduling Questions
Other Questions