CLIENT INTAKE QUESTIONNAIRE

In order for WeeSleep to get a better understanding of the sleep issues your little one is having, it is important you answer a few questions about your child's sleep habits prior to our consultation.

Please answer the below questions in the spaces provided and send the completed form to your consultant 48 hours before your scheduled consultation.

Parent's Name



Child's Name



Birthday



Mailing Address
Street



City



Zip Code / Postal Code



Country



Email Address



Phone Number



1. How old is your child? Please provide age and birthday.



2. How much does (s)he weigh in lbs.?



3. Was your child born prematurely?

yesno

If yes, how many weeks?



4. Did (s)he have colic or reflux?

yesnot sureno

If yes, was this diagnosed by a medical professional?



5. Does your child take any medication?

yesno

If yes, what?



6. Have there been any health issues or concerns?

yesno

If yes, please describe



7. Have you spoken to your doctor about your child's sleep difficulties?

yesno


8. What time does your child wake to start the day?



9. What happens at this time? Are they given a bottle, breastfed, start with solids etc.



10. What signals do you notice your child gives when (s)he is tired?

Gets crankyStares into spacePulls EarsOther


11. Does your child sleep in a crib?

yesno

If no, when did you move him/her out of the crib and why?



12. Does your child use any of the following to sleep in?

SwaddleSleep SackMerlin SuitOther


13. Does your child have a favourite "snuggly buddy?"

yesno

If yes, does it have a name?



14. What time of day does the first nap usually occur and where does it take place?



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

Being HeldFeedingLaying WithRubbingStrollerCar RideSootherSingingBouncingOther


16. How long does this nap last?

30-40 minutes1 hr1.5 hrs2 hrsother


17. What time of day does the second nap occur?



18. How does your child fall asleep for this nap?

Being HeldFeedingLaying WithRubbingStrollerCar RideSootherSingingBouncingOther


19. How long does this nap last?

30-40 minutes1 hr1.5 hrs2 hrsother


20. Is there a third or fourth nap during the day or early evening? If yes, what time(s)?



21. How does your child fall asleep for these naps?

Being HeldFeedingLaying WithRubbingStrollerCar RideSootherSingingBouncingOther


22. What time do you start getting your child ready for bed?



23. What do you do with your child when getting them ready for bed? Please list in order. (For example: bath, brush teeth, sing songs, read stories, play a game etc.)



24. What time does your child actually fall asleep at bedtime?



25. How does your child fall asleep at this time?



26. Does your child use a soother/pacifier?

yesnosometimes


27. What happens during the night? Include best and worst case scenarios



28. Have you read any books about infant sleep? If yes, what book, and have you tried any suggestions in the past?



29. Was there a time your child slept well and then things changed? If yes, please describe.



30. Does your child have any siblings? If yes, what are their ages and do they share a room?



31. Does your child attend Daycare, preschool, or elementary school? If so, whats days and for how long.



32. Do you have a nanny or other caregivers? If yes, what days and times?



33. Do you have a furry member of your family who likes to make noise?



34. Is there anything else you'd like to share before we meet?



Who may I thank for referring you?