Sleep Questionaire - Blissful Baby Services

Blissful Baby Sleep Questionaire

Child's Name

First

Last

Child's Age

Birthday

Parent's Name

First

Last

Occupation

Phone Number

Consultation type

How did you hear about Blissful Baby Service?

Why did you choose Blissful Baby Services?

Is your child In a Crib or Bed?

Child's History

If applicable, what is your child’s current weight/growth percentile?

When was your child’s last visit to their doctor? Pediatrician/ Physicians Name

Were your child’s sleep issues discussed? If so, please explain what concerns were brought forward and what the doctor advised.

Does your child have any medical issues we should be aware of (reflux, allergies, etc.)?

Is your toddler/child potty trained?

Child's Daily Routine

What time does your child wake for the day?

How many times per day does he/she nap? Please list the time and duration of each of the naps.

Please describe your wind down routine (if you have one) before naps.

Please describe your child’s bedtime routine, or any variances from the nap wind down routine.

Do you know what signs your child gives to show they are tired and ready to sleep? If so, what are they?

What time is your child’s bedtime?

How long do they take to fall asleep?

Can they fall asleep without your help or presence?

Does he/she experience night waking’s? If so, how many per night?

How long is the child awake for, during a night waking?

How do you handle them/what is your response? Please be specific as possible.

Please list your daily schedule below; include naps, playtime, daycare times, special activities or programs they attend and bedtime; Be as specific as possible.

Temperament and Personality

How would you describe your child’s temperament/mood/attitude during the day?

How would you describe your child’s personality? Does your child have any fears?

Please describe you and your partner’s (if applicable) personalities.

Please describe how you and your partner handle stressful situations.

Child’s Sleeping Environment

Where does your child sleep? Please list all of the environments that your child typically sleeps in below; (i.e. crib, bed, family bed, stroller, car, etc.)

Please rate the level of darkness in his/her room- 1 being bright and sunny, and 5 being absolutely dark.

Does your child have a lovey, blanket or stuffed animal that they use to fall asleep? If yes, how is it incorporated into the bedtime routine?

Goals and Expectations

When you put your child to sleep please describe their state of wakefulness from 1-5, 1- being wide awake and alert, and 5 being in a very deep sleep;

How long do you expect sleep training/routine setting to take?

How long would you like sleep training to take before you see some result, even small ones?

Parent History and Family Philosophy

Please tell us what your goals are for your child in terms of their sleep/routine. If you have more than one, please list in order of importance.

Please add anything that you would like to share or feel we should know.

Have you read any books on sleep; if yes which ones? What did you think of them?

Are there any sleep philosophies you agree with? If yes, please explain why;

Are there any sleep philosophies that you are uncomfortable with? If yes, please explain why.

Have you read any books on parenting, discipline and/or behavior management? If so, which ones?

If applicable, what style of behavior management or discipline do you follow?

Do you feel it’s effective? Why or why not?

What is your parenting philosophy? What is your partner’s?

How do you feel when your child cries in the day? How about at night? How do you feel about crying, in general?

Is everyone committed to your child getting restful and restorative sleep?

What roadblocks or hindrances do you see that may inhibit progress-either personality wise (ie-one parent is impatient, or easily frustrated, etc.) or schedule wise (day care, work schedules, appointments, etc.)?

Parent’s Sleep History

How many hours a night do you estimate you and your partner (if applicable) are sleeping?

How did you sleep before children?

Are you sleepy during the day?

If you answered “yes”, does that interfere with

Work?

Driving Safely?

Taking care of the children?

Having a social life?

If you are human, leave this field blank.