"*" indicates required fields Parent's Name(s)* Cell Phone*Alternate PhoneEmail* Street Address* City* State* Zip Code* What is the biggest challenge for your family in regard to sleep?What are your sleep goals for your family?Name of Child Estimated Due Date MM slash DD slash YYYY Actual Delivery Date MM slash DD slash YYYY Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.) Yes No If yes, please explain:*Does your child mouth breath or snore? Yes No My child typically takes naps or sleeps at night in: (check all that apply) Crib Family bed Toddler bed While being held Swing/bouncer Car seat Infant Carrier Stroller Rate the darkness of your child's regular sleep environment during the day and night?Day sleep Bright light Somewhat light Somewhat dark Pitch black Night sleep Bright light Somewhat light Somewhat dark Pitch black Rate the noise level of your child's sleep environment?Day sleep Silent Very occasional subtle noise Occasional noise Loud and noisy Night sleep Silent Very occasional subtle noise Occasional noise Loud and noisy I use the following to help my child sleep: (check all that apply) Rocking Patting Shushing Nursing/bottle Being held White noise Lovey toy Pacifier Swaddling Walking/moving Car/Stroller ride TV Music Other If Other*When I put my child to sleep he/she is: My child wakes for the day around? When my child wakes up he/she is: How many naps a day does your child typically take? 1 2 3 4 5 None Do you currently have your child on a set schedule for naps and bedtime? Yes No What time does your child take nap 1, 2, 3, etc and how long is each nap usually? How would you describe the overall mood of your child? Happy, cranky, laid back? Is your child in daycare, if yes, please explain schedule? Drop off, naps, pick up? My child usually goes to bed around? Our normal bedtime routine is? If your child wakes at night, how many times and how do you respond? Who typically handles night waking? Does your child nurse or bottle feed Yes No If yes, how many feedings and at what time?* What developmental milestones (if any) has your baby accomplished? Check all that apply Rolling from belly to back Rolling from back to belly Sitting up But can't lay back down Crawling Standing in Crib Any other information you would like to share?Consent I have read and understand the Healthy Care Practitioner and Liability/Disclaimer
