Preliminary Sleep Questionnaire for Child:
Welcome,
Would you please take the time to answer some questions about your child 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 child’s name?
What is your child’s date of birth?
What are both parent’s names (and names of other caregivers)?
Does your child have any siblings? Yes or No. If yes, what are their names and ages?
What are their doctor’s name and address?
Was your child born before 36 weeks gestation? Yes or No? If Yes: what gestation?
Have there been concerns with weight gain in the past?
Yes
No
Are they under paediatrician care? Yes or No? If yes, for what medical concern
If there are health concerns … have you confirmed with your GP or pediatrician if your child is well enough to learn independent sleep skills? I do ask for you to get the go-ahead before we start.
Yes
No
Is your child on any medication? Yes or no. If yes, what, and what does it treat?
Does your child have any food allergies or sensitivities? Yes or No? If yes, what to?
Does your child snore or mouth breath/have noisy breathing (other than when congested/ ill)?
Yes
No
How would you rate your child’s eating habits?
Picky eater
Healthy appetite
Only eats same 5 things
If still having milk, when is this given through the day?
Before Nap
After Nap
At Bedtime
In the night
No consistent pattern
If having milk feeds are they via breast feeds, in a sippy cup or bottle?
If a bottle, what is the total volume taken per 24 hours?
What would an average day of food consumption look like?
Breakfast
Snacks
Lunch
Dinner
Treats
What time is dinner/tea time?
What snack does your child have right before bed?
Is your child meeting all their expected developmental milestones? Yes or No? If no, what milestone are they still working on?
Are there any behavioral issues or concerns?
Yes
No
What activities or sports does your child do in the week or have to attend due to siblings being booked activities? Give day, time and length of activity.
Are there any concerns with your child’s communication skills?
Yes
No
How does your child respond to instruction or disciple from you, and or, from others?
Accepts
Tantrum but settles
Melt-down
Does your child handle transitioning from one activity to another well?
Yes
No
Does your child become agitated or introverted when responding to stress?
Do you have a childminder at home or are you at home full time?
Is your child in daycare, crèche or school? What days?
If your child is away from home, how far is the establishment from your house? (How long does it take to travel there by car or pram)?
What time does daycare, school start and finish?
Sleep Questions:
Please tick what applies to the room your child will be sleeping in e.g. busy or minimalistic, blackout blinds or curtains – or both, any night lights on or sounds playing at night
Where does your child sleep?
In their own room
Your room
With a sibling
In a cot
Bed
Your bed
Other
Does your child have their own room to sleep in?
Yes
No
Is this shared with anyone?
Yes
No
On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime and through the night?
1
2
3
4
5
6
7
8
9
10
How far is the cot/bed end from the bedroom door in their bedroom (in metres):
What time does your child start the day?
What happens currently when they wake? (Are they given a bottle, breastfeed, solids, play etc.)
How many hours of screens/TV does your child watch?
Is this in the hour before bed?
Yes
No
Does your child ever take a daytime nap?
Yes
No
If napping during the day, tick where this occurs:
In room in a cot
On you
Out on the go
And what in?
In their room
In a cot
Your bed
In a sleep-bag
What time of day does the first nap usually occur?
How do you or your caregiver get your child to sleep for this first nap?
Feeding (bottle or breast feed)
Dummy
Holding
Rocking
Bouncing
Hair twirling
Music
Motion in pram
Carrier or car
Mum or Dad presence/hand holding
Other
How long does this nap last?
Does this change on the days your child goes to daycare/ Crèche?
What time do you start the bedtime routine?
Do you have a bath? Yes or no? If yes, do you wish to utilise this daily in your bedtime routine?
What does your routine include when getting ready for bed? (e.g. bath, brush teeth, sing songs, massage, read stories, play a game, feed, medications etc.)
How long is the bedtime routine?
How long does it take your child to fall asleep at bedtime?
What time do they typically fall asleep at bedtime?
What is the scenario/what has to occur when your child is falling asleep?
Bottle/breastfeeding
Dummy
Holding
Rocking
Bouncing
Hair Twirling
Music
White Noise
Motion
Bed Sharing
Parent Presence/Hand Holding
Other
If you co-sleep/sleep next to your child, are you happy to discontinue this?
If you use a dummy are you happy to drop this?
How many night wakes during a typical night?
How many during a “bad night”?
How many during a “good” night?
What’s the average length of a wake up?
If bedsharing occurs, what is the typical time this start from in the night?
If still feeding in the night. Are you ok to drop night feeds “cold turkey”
Did your child used to sleep well? Yes or No. If yes, what age did it change?
What are the most difficult issue/s around your child’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
Parent History:
Has your family experienced any major life changes, loss or trauma recently?
Any personal history with depression, anxiety or major illness?
Yes
No
If yes. Is this currently?
Do you currently work? Yes (full time or part-time), no, on maternity leave, stay at home parent?
Does your spouse work? Yes (full time or part time), no, on paternity leave, stay at home parent?
Do you work both work away from home or at home?
Do you have activities that you have to take your child or siblings to during the day? If so, please give the particular days and times of classes etc.
Are you ok with placing on hold your classes on week one to prioritise learning and practicing sleep skills. (We can then plan how to navigate attending these around sleep in week two).
Yes
No
What would be your number 1 sleep goal working together?
What’s your main motivation to make changes with your child’s sleep?
What’s your biggest fear about 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 child can sleep well?
Is there a family history of sleep problems?
Do you have support during the program?
Yes
No
Is everyone in the household committed to seeing your child learn independent sleep skills?
Yes
No
Have you read any books about infant sleep?
Yes
No
Have you already tired some sleep training method that has been unsuccessful? Yes or no? What was it?
What are you most looking forward to once your little one can sleep well?
Please provide your postal address so I can keep in touch with you or send any future referral thank you’s.
How did you hear about Flutterby Sleep Consultancy?
That’s it! Thanks so much for taking the time to complete this and making a commitment to getting your child to sleep well. I look forward to our telephone call to go through the plan!
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