Baby's Name
First Name
Last Name
Baby's Birth Date
MM
DD
YYYY
Date of last pediatrician visit
MM
DD
YYYY
Baby's Due Date
MM
DD
YYYY
Baby's Height
Baby's Weight
Mother's Name
First Name
Last Name
Father's / Partner's Name
First Name
Last Name
Address
Please provide your address so I can send you referral and/or birthday gifts
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Describe your home and who lives in it.
List any current and/or past medical concerns for your baby:
List any complications during your pregnancy:
What time does your baby go down for bed at night?
What time is your baby waking up for the day in the morning?
Describe the environment that your baby sleeps in during the day (naps):
Example: Ergo, crib, bassinet, swing, on mom, etc. Include description of room/environment.
Describe the environment that your baby sleeps in during the night:
What room(s) does your baby sleep in?
Describe the temperature, sound level, light, and stimuli in the sleeping environment:
What position does your baby sleep in most of the time?
Back
Tummy
Side
Describe naps:
Include time of day, duration, and routine (if any)
Do you swaddle your baby? If so, how often?
About how many times per night is your baby waking up?
Describe how you and your partner put your baby to sleep for naps and bedtime:
Example: rocking, co-sleeping, swing, patting, etc.
Do you have another caregiver/daycare that may do things differently? If so, please describe:
What (if any) objects are you using to help your baby sleep or be calm?
How much natural sunlight is your baby exposed to during the day?
Is your baby breastfed, formula fed, or both?
Breastfed
Formula
Both
Has your baby started solid foods? If so, when did they start?
Are there any known allergies, to food or otherwise? If so, please list:
List your baby's feeding times, what they eat, and how much:
If using formula, please indicate which brand and how long they've been on it:
Do you believe your baby has colic?
Yes
No
Not sure
Does your baby have reflux or GERD? If so, when was it diagnosed?
Has your baby had any vaccinations? If so, which ones and when were they given?
Does your baby do any of the following when sleeping?
Do you think your baby could be waking with nightmares? If so, please describe:
What is your baby's temperament like?
Easy
Slow to Warm Up
Difficult
Mixed
Not Sure
Describe your baby's activity level:
Describe your baby's attention span:
How adaptable is your baby?
He/She can adapt to anything
Not at all
It depends on the day
Not sure
How distractible is your baby?
Very distractible
Not at all
Somewhere in the middle
Not Sure
Has your baby developed predictible eating and sleeping patterns?
Yes
No
Not Sure
Describe the products you use with your baby. If using a stroller, bassinet, carseat, how long ago were the products made/purchased? Are they made from natural non-toxic materials?
Do you use organic sheets?
Yes
No
Does your baby wear clothes made from organic materials?
Yes, always
Yes, mostly
No
Not Sure
When was the room that your baby sleeps in last painted?
Do primary caregivers wear any fragrances like perfume or in hair/skin products?
Yes
No
Sometimes
Not Sure
What skincare and bath products do you use for your baby?
What kind of diapers do you use for your baby?
What kind of cleaning products do you use in the home?
Describe your current sleep concerns:
Describe your sleep goals for your baby:
Do you consider your child’s sleep a small problem, serious problem, or not a problem at all?
Small Problem
Serious Problem
Not a problem at all
Have you tried any sleep training methods in the past? Please describe your experience:
How do you feel about allowing your baby to cry?
Cannot tolerate it at all
It's okay for a few minutes
Not a problem when needed
Making any kind of changes to a child’s routine and comfort zones often comes with a bit of temporary upset. How long do you think you would be comfortable letting your baby cry while adjusting to a new routine?
Not at all
1 minute
3 minutes
5 minutes
10 minutes
20 minutes
30 minutes
As long as necessary
While your child is learning a new sleep routine would you be most comfortable
Have you read any books or internet information by any of the well-known sleep experts?
Is there an expert’s technique that you like?
Is there an expert’s technique that you are NOT willing to work with?
What is your relationship status with your partner?
e.g. married, separated, divorced, etc
What support systems do you currently have in place
e.g. supportive partner, siblings close by, parents close by, mommy group, none, etc.
What is/was your occupation? Do you plan to go back to work? If so, when?
What do you plan to do for childcare if you're returning to work?
Is there anything else I should be aware of or give consideration to when making a sleep plan for your baby? (Examples: pregnancy, moving, going back to work, visitors, etc.)
