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.

Before we begin, please share with me why you have chosen to seek help with your child's sleep. What issues are you currently facing

Preferred email we use*

Who referred you? How did you hear about Sleep at Last?

What size t-shirt do you wear?

Full Name

Partner's Name

Mailing Address

What time zone are you in?

Who lives in home with the child? Includes names and ages of siblings.

Medical Questions

Child's full name (and nickname if preferred).

Child's date of birth.

Was your child premature? If so, what is his/her adjusted age?

What was your child's birth weight? What is your child's current weight? Is your child gaining weight appropriately or are there weight concerns?

Is your child breastfed, formula fed, or a combination of both? If breastfed, any supply concerns? Is your child eating any solids?

What does your child's current feeding schedule look like? How many ounces of milk is your child getting per day?

Have there been any health issues or concerns? (this may include anything from developmental delays to weight gain issues to medical diagnoses). If yes, please describe.

Is your child currently under the care of a doctor, other than her pediatrician for routine visits?

Did/does your child have a tongue or lip tip? Has this been addressed? Is your child under the care of a therapist?

Does your child have reflux or a history of reflux?

Is your child on any medication or supplements (vitamins, melatonin, etc)? If yes, please list and describe for what purpose.

Does your child snore or is he/she a heavy mouth breather?

Milestone Assessment - Please check off the skills your child has MASTERED:

None yet

Rolling back to front

Rolling front to back

Rolling both directions

Sitting unassisted

Crawling

Standing - holding onto object

Standing - unassisted

Walking

Please describe any skills your child is currently working on but has not yet mastered.

How you spoken to your doctor about your child's sleep difficulties? If so, what did the doctor say?

Who is your child's pediatrician? May I contact him/her regarding our time together?

Dietary Questions

What does your child's feed schedule look like?

Is your baby breastfed?

Is your baby exclusively breast or bottle-fed or a combination? Please share details.

Generally, how long are nursing sessions?

Does/did baby have any latching issues?

Does baby frequently fall asleep at the breast?

Does baby have full feedings or does he/she tend to snack/graze feed throughout the day?

How long in between feeding sessions?

Are you seeing a Lactation Consultant? If so, please share any information that may be relevant/helpful.

Is there any other information I should know about nursing?

Is your baby formula fed?

Generally how long are feeding sessions?

How many ounces does baby generally take per feeding?

How many ounces does baby generally drink per day, per night, and per 24 hours total?

Does baby have any difficulties taking the bottle?

Does baby fall asleep frequently while feeding?

Does baby have full feedings or does he/she tend to snack/graze on bottles throughout the day?

If there any other information I should know about formula feeding?

Is baby drinking another source of milk, in addition or in replacement of breastmilk/formula?

If so, what kind of milk? Does he/she like milk?

Is baby using a cup for milk? If so, what kind of cup?

What time(s) of the day is baby getting milk? How much milk per 24 hour period?

Is there any other information I should know about milk?

Is your baby eating solids?

Does your child have any food allergies or sensitivities?

How many time per day is baby eating solids?

Does he/she like solids?

Share an example of daily food intake (what kind of foods and timing).

Sleep Questions

Was there a time when your child did sleep well, and things changed?

Where does your child sleep?

Crib

Bassinet

Pack-n-Play

Bed

In their own room

In our room

In room with sibling

With Sibling

Where does your child sleep? Do he/she share a room with anyone? If no, any plans of this happening?

Does your child use a pacifier of lovey? If so, please explain.

Does your child sleep well on the go (carseat, stroller, baby wearing)?

What do you dress your child in for sleep (PJs, sleep sack, etc)?

Morning

What time does your child naturally wake to start his/her day?

Do you have to wake your child any days of the week? If so, why and what time and what days do you have to wake your child?

What is your baby's mood upon waking in the morning?

What is a typical morning like in your household? What happens when baby wakes?

Naps

What signals do you notice your child gives when he/she is tired?

Do you base your child's nap(s) primarily off of wake times, sleep cues, the clock, or varies? Please explain.

If you use wake times, what wake windows are you using? If you use a clock-schedule what time are naps?

What is the sleep environment like for naps? How dark is it? How loud or quiet is it?

What times does the first nap usually occur?

How do you get your child to sleep for this nap?

How long does this nap last?

Tell me about the rest of your child's daily naps. How many naps does your child take, what time, where, how does he/she fall asleep for other nap(s), and how long do they last?

On average, how many naps does your child take per day?

Daily Childcare

Is your child cared for by someone other than you?

Yes

If yes to the above question, who cares for your child during the day? What day(s) is your child cared for by someone other than parents?

Is your child cared for at home or at another location? Please describe.

If your child is cared for in a location outside of the home, how long is the drive to get there? And what time do you drop off and pick up your child?

What is the sleep environment like away from home?

Do you see any potential concerns with making changes to your child's sleep with their caregiver?

Will there be any changes to your child's caregivers/locations in the near future?

Bedtime

Does you child use any of the following?

Pacifier

Lovey / Transitional Item

Night Light

Hatch

Sound Machine

Room Darkening Shades / Curtains

OK to Wake Clock

What time do you start getting your son/daughter ready for bed?

What is your child's bedtime routine (for example, bath, feeding, teeth, PJs, books, into bed)? Please list each step, in order.

How does your child fall asleep at bedtime? Be as specific as possible.

What time does your child actually fall asleep at bedtime?

Where does your child sleep? Is it the same location all night? If not, please explain.

Sleep Props_Infant

Rocking or bouncing

Feeding - nursing or bottle

Co-sleeping / laying with them

Other

Night Wakings

Does your child have any night feeds? If so, on average, how many night feeds does your child have?

If breastfed, how long are nursing sessions in the night? Is this a comfort nursing session or is baby taking a full feed?

If bottle fed, how many ounces per night feed? Is baby finishing the bottle?

What is best case scenario overnight? How often does this happen?

What is worst case scenario overnight? How often does this happen?

Describe the typical or average night.

Scheduling Questions

Does your family have any daytime or evening obligations (such as clubs, classes, school pickups, sports, etc.) would interfere with baby's naptime, or ability to keep a consistent bedtime routine and bedtime? If so, please sure details on your schedule.

Does your family eat dinner together as a family? If so, what time?

Is there a specific schedule that you need for your child (specific bedtime, morning wake up, or nap time?) If not, please indicate a preferred wake time or bedtime, so I can create an appropriate schedule for your child.

Other Questions

I will use all of the information that you have provided to create a sleep plan for your child, based upon your family's needs. You know your child best and you know your family obligations, as well as your preferences and ability to tolerate crying. At this time, do you feel you may prefer being in the room with your child as he/she is setting to sleep or do you prefer (or need) to be out of the room and checking in as your child is setting to sleep? We will absolutely discuss this during our consultation, but I will take your preference into consideration to ensure we decide on the best option for your family.

What are the most frustrating or difficult issues for you around your child’s current sleep habits?

What are your goals for your child's sleep? What would you like to see as a result of our time together?

What are your personal goals once your child is sleeping well? What would you like to see happen for yourself or your partner as a result of our time together? What do you miss most about having a sleeping child? This could by anything be simply getting some sleep yourself, or taking a bubble bath, working out, having an adult only conversation, having a date night, THE POSSIBILITIES ARE ENDLESS...

Is there anything about the family, parents, parenting styles, perceptions, etc. that would inhibit your commitment to working on your child's sleep and independent sleep skills? Any particular concerns or worries?

Has your family experienced any major life changes recently, or anything coming up in the near future that could be affecting your child?

Have you read any books/articles/blogs/etc about sleep and have you tried any suggestions in the past? If so, what was the result if you did? Anything particularly helpful or not helpful?

Is there a family history of depression or anxiety disorders?

Are there any medical conditions that may affect your participation in sleep training, such as sleep apnea, anxiety, depression?

Are there any concerns or worries about getting your child sleep well?

Is your partner on board with these changes? Who will be working on the sleep plan with you? Do you feel you will be supported by partner/family through this process?

When implementing our program, we need 3 weeks of consistency. Do you have any upcoming trips, outings, plans of guests, etc that may interfere with being consistent? If yes, please share dates and details.

Do you have any plans for soon after the completion of our program? Whether that be big outtings, guests, or trips planned? If so, please share details.

Is there anything else you’d like to share with me that you think I should know before we meet? Do you have any questions or concerns at this point?