Preliminary Questionnaire for Infant
Welcome,
Would you please take the time to answer some questions about your infant and their sleep habits. This will help me better understand your unique struggles and challenges you are facing … so I can design your plan to best reach your outcomes and restore sleep.
Full Name
Email*
What is your infant’s name?
What is their date of birth?
Parent’s names (and names of other caregivers)?
Does your infant have any siblings? Yes or No. If yes, what are their names and ages?
How much does your infant weigh?
What are their Doctor’s name and address
Are they under paediatrician care? Yes or No? If yes, for what medical concern?
Was your infant born before 36 weeks gestation? Yes or No? If Yes: what gestation?
Did they have colic?
Yes
No
Does your infant snore or mouth breath/have noisy breathing (other than when congested/ ill)?
Yes
No
Does your infant have any food allergies or sensitivities?
Yes
No
With what?
Have there been any health issues or concerns?
Yes
No
If yes, are they being treated, or have they been resolved?
If being cared for under GP/Pediatricians, have you confirmed with them if your infant is well enough to learn independent sleep skills? I do ask for you to get the go-ahead before we begin
Yes
No
Is your infant on any medication?
Yes
No
If yes, what medication and what does it treat?
Have you spoken to your doctor about your infant’s sleep difficulties? Yes or No? If yes what was the advice?
What developmental milestones has your infant met and what developmental milestones is your infant working on?
They can roll front to back, and back to front
Sit up
Crawl
Stand
Walk
Talk
Other
What time does your infant wake to start their day?
What happens at this time? (Are they given a bottle, breastfeed, solids, play etc?)
What signals do you notice your infant gives when tired?
Yawn
Rub Eyes
Rub Ears
Cry
Stare
Other
Where does your infant sleep?
In their own room
In your room
In their siblings room
In a cot
Moses basket
Infant sleep aid
Adult bed
Does your infant have their own room to sleep in?
Yes
No
What age are you planning to utilise this room?
Will this room be shared with anyone?
Yes
No
If any sleep aids (such as a sleepy head or similar) or cot bumpers? Are you happy to discontinue there use as per safe sleep guidance?
Yes
No
Does your infant use anything external to help get to sleep?
Feeding (bottle or breast feed)
Dummy
Holding
Swaddling
Rocking
Bouncing
Hair twirling
Music
Motion in pram
Carrier or car
Mum or Dad presence
If you co-sleep/sleep next to your infant, are you happy to discontinue this?
Please tick items in your the nursery your infant will be sleeping
Busy or minimalistic
Blackout blinds or curtains
Any night lights on
Sounds playing at night
How far is the cot end from the bedroom door in their bedroom (in metres):
Rate the level of darkness in the room where your infant sleeps? (1-being bright and sunny…10 being absolutely dark).
1
2
3
4
5
6
7
8
9
10
Does your infant watch TV or play on the computer/tablet? If so at what time of the day usually/how long for?
If napping during the day, where does this occur (in room in a cot, on you, out on the go?) and what in? (In their room, in a cot, in a sleep-bag)?
What time of the day does the first nap usually occur?
How do you or your caregiver get your infant to sleep for this first nap?
Feeding (bottle or breast feed)
Dummy
Holding
Swaddling
Rocking
Bouncing
Hair twirling
Music
Motion in pram
Carrier or car
Mum or dad presence
Other
How long does it last?
If there is a second nap what time of day does the second nap occur?
How does your infant fall asleep for this nap?
Feeding (bottle or breast feed)
Dummy
Holding
Swaddling
Rocking
Bouncing
Hair twirling
Music
Motion in pram
Carrier or car
Mum or Dad presence
Other
How long does this nap last
If any other naps please give a rough time, how your infant gets to sleep for this nap, and how long it lasts:
What time do you start getting your infant ready for bed?
Do you have a bath? If yes, do you wish to utilise this daily in your bedtime routine?
What does your routine include when getting ready for bed?
Bath
Brush
Teeth
Sing songs
Massage
Read Stories
Play a game
Feed
Mediations
Other
What time do they actually fall asleep at bedtime?
How do they fall asleep at this time?
Feeding (bottle or breast feed)
Dummy
Holding
Swaddling
Rocking
Bouncing
Hair twirling
Music
Motion in pram
Carrier or Car
Mum or Dad presence
Other
How many night wakes during a typical night?
How many during a “bad night”?
How many during a “good night”?
What’s the average typical length of each wake up?
If bedsharing occurs, what is the typical time you switch to this in the night?
If still feeding in the night. Are you wishing to drop down feeds “cold turkey” or use a “wean down” method?
How many feeds would you feel comfortable keeping as a maximum per night?
How long is the usual stretch of hours between feeds in the night, e.g. 3 hourly, 4, 6?
Do you use a dummy at all?
Yes
No
If yes … are you happy to stop using it?
Yes
No
Do you incorporate a “dream feed”?
Yes
No
Are you happy to start reducing/stop bottle feeds if your infant is over 12-months of age and make the move to a sippy cup?
Yes
No
Did your infant used to sleep well? Yes or No. If yes, what age did it change?
What are the most difficult issue/s around your infant’s sleep?
Getting to sleep at bedtime
Cries a lot around bedtime
Can’t get to sleep themselves
Night wakes
Needs you in order to resettle
Early morning wakening’s
Difficulty in napping in the cot
Reluctance to nap
Gets overtired easily
Other
Where are milk feeds placed through the day?
Before naps
After naps
No consistent times
If taking solid foods, is this at breakfast, lunch and evening time?
Does your infant have a good appetite and showing interest in solids?
Yes
No
Has your family experienced any major life changes, trauma or loss recently?
Any personal history with depression, anxiety or major illness?
Yes
No
If yes, is this currently?
Do you currently work?
Yes. Full time
Yes. Part time
No. On maternity leave
No. Stay at home parent
Does your spouse work?
Yes. Full time
Yes. Part time
No. On paternity leave
No. Stay at home parent
Do you work both work at home or away from home?
Do you have activities that you have to take your infant or siblings to during the day? If so, please give the particular days and time/length of classes etc.
Are you ok with placing on hold your classes on week 1 to prioritise learning and practicing sleep skills. (We can then plan how to navigate attending these around sleep in week two).
Yes
No
Is your infant in daycare?
Yes
No
If yes, what days?
If yes. How far is the daycare from your house? (How long does it take to travel there by car or pram?)
What time does daycare start and finish?
Does the number of naps change on a daycare day versus a home day?
Is everyone in the household committed to your infant getting restful and restorative sleep?
Do you have support during the program?
Have you read any books about infant sleep?
Yes
No
Have you already tired some sleep training method that has been unsuccessful?
Yes
No
What was it?
What would be your number one sleep goal working together?
What’s your main motivation to make changes with your infant’s sleep?
What’s your biggest fear around sleep training?
What has held you back from making changes with their sleep up to now?
What are you looking forward to most once your infant can sleep well?
Is there a family history of sleep problems? Yes or no?
Please provide me with your home address so that I can keep in touch with you and send on any future referral thank you’s:
How did you hear about Flutterby Sleep Consultancy: please give the name of the main/first referrer if from a group.
That's it – you made it! Thanks in advance for getting this back to me, and I look forward to our consultation call and getting you all some much-needed sleep!
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