Child's Name
*
First Name
Last Name
Child's Date of Birth
MM
DD
YYYY
Child's Height
Child's Weight
Child's Gender
Male
Female
Other
Date of last pediatrician visit:
School Grade (if applicable)
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
Phone Number:
(###)
###
####
Parent(s)/Guardian(s) Name(s)
Parent(s)/Guardian(s) Age(s)
Person answering questionnaire:
Sibling(s) Name(s) and Age(s)
How would you describe your child's temperament?
Easy going, strong willed, shy, anxious, etc.
Is the mother pregnant or expecting a new child to be coming into the home?
Describe any recent changes to the family in the past 6-12 months:
Example: birth of new sibling, death, divorce, separation, marriage, addition of step-siblings, moved to a new house, grandma moved in, parents have been fighting, car accident, etc.
Describe your child's sleep problem(s):
How long has the problem been occurring?
What are your sleep goals for your child?
What time does your child go to bed at night? What time do they wake up in the morning?
List all medications your child is currently taking:
Include medication name, dosage, time given, route given, reason for medication, prescribing doctor, and start date.
Describe any current or prior medical conditions or concerns:
Example: asthma, down syndrome, autism, allergies, heart monitor, etc.
Describe any complications during pregnancy:
Example: baby born premature, emergency C-section, etc.
Please describe your birth story:
List any complications, how many weeks early/late, medications used, length of labor, etc.
Who is living in the child's home?
Describe the primary caregiver(s) work situation:
Describe if both parents work, full or part time, in or outside the home, if a lot of travel is involved, night shifts, etc.
Describe your childcare situation:
Example: daycare, preschool, school, after/before school program, nanny, grandparents watch child, etc.
Describe the activities your child participates in on a daily basis:
Check activities your child does while in bed:
Describe a typical meal for your child (breakfast, lunch, and dinner):
Example: picky eater, eats a variety of foods, no protein, family is vegan, will only eat sweets, etc.
Was your child sleep trained as a baby? If so, please describe method used:
Are you familiar with any sleep training methods?
Describe your comfort level wtih letting your child cry:
Example: not comfortable at all, it's okay for a short period of time, I've never let my child cry more than a few minutes, etc.
Describe the chld's sleep environment:
Include details such as bed, light (real and artificial), noise, temperature, etc.
Check all things your child does while sleeping:
Has your child ever stopped breathing at night?
No
Yes - nightly
Yes - a few times a week
Yes - just a few times ever
Have you ever had to shake or move your child to get them to breathe again?
No
Yes - once or twice
Yes - a few times a week
Yes - nightly
Does your child sleep in a room alone?
Yes
No - shares a room with family member
No - shares a bed with family member
Is there regular “lights out”, bedtime each night?
Yes
No
Describe your child's bedtime routine:
On average, how long does it take your child to fall asleep?
Is there difficulty or bad behavior at bed time? If yes, please describe:
How often does your child wake up at night?
0 times
1 time
2 times
3+ times
Have you started toilet training? If so, please describe where they are at or when you plan to start:
Does your child wake up and go to the restroom at night?
No - still in diapers
No - in underwear & wets the bed
No - in underwear & wakes up dry
Yes
Does your child wet the bed?
No
Yes - every night
Yes - a few times a week
Yes - every once in a while
What time does your child get up in the morning?
Is your child difficult to awaken?
No
Yes - always
Yes - sometimes
Has your child ever had “sleep walking” episodes?
No
Yes - once or twice
Yes - more than a few times
Yes - nightly
Have you ever been awakened by the sound of your child, screaming or crying at night?
No
Yes - once or twice
Yes - often
Has your child ever come to you at night because of “bad dreams”?
No
Yes - once or twice
Yes - more than a few times
Yes - nightly
When asleep, does your child rock his/her body?
Yes
No
Not sure
When asleep does your child bang his/her head on the pillow, mattress, or headboard?
Yes
No
Sometimes
Does your child regularly nap during the day?
Yes
No
If your child naps, describe the time of day, duration, and routine:
How long do you think children the same age as your child should sleep each night?
Has a teacher ever told you that your child “day dreams” or has difficulty paying attention in school?
No
Yes
My child isn't in school yet
Has your child ever fallen asleep in school?
Yes
No
My child isn't in school
Has your child ever simply stopped his/her activity and taken a nap where he/she was?
No
Yes - daily
Yes - once in a while
Has your child ever seemed to be dreaming (seeing images or hearing sounds) while still awake?
No
Yes - Daily
Yes - Weekly
Yes - Once in a while
On average, how many caffeinated beverages (chocolate milk, cola, tea, coffee) does your child drink a day?
0
1
2
3+
Has your child ever seemed to lose control of his/her arms (dropping objects) or leg (stumbling) involuntarily?
No
Yes - once or twice
Yes - often
Has your child ever become weak or unsteady when excited, surprised or emotional (laughing or crying)?
No
Yes - once or twice
Yes - often
Does your child still have their tonsils?
Yes
No - they were recently removed
No - they were removed 6+ months ago
Has a health professional ever said that your child has Attention -Deficit Disorder (ADD) or Attention-Deficit /Hyperactivity Disorder (ADHD)?
No
Yes - but no formal diagnosis
Yes - with a formal diagnosis
What are some of your child's favorite things?
Examples: favorite foods, toys, activities, TV shows, games, etc.
Is there anything else you'd like me to know?
