Consultant Name(s) (required)

    Parent's Name(s) (required)

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    Alternate Phone

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    Street Address (required)

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    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

    Actual Delivery Date

    Does your child have any significant medical history? (ex. reflux, colic, allergies, surgeries, special needs, etc.)
    yesno

    If yes, please explain:

    Does your child mouth breath or snore?
    yesno

    My child typically takes naps or sleeps at night in: (check all that apply)
    CribFamily bedToddler bedWhile being heldSwing/bouncerCar seatInfant CarrierStroller

    Rate the darkness of your child's regular sleep environment during the day and night?
    Day sleep
    Bright lightSomewhat lightSomewhat darkPitch black

    Night sleep
    Bright lightSomewhat lightSomewhat darkPitch black

    Rate the noise level of your child's sleep environment?
    Day sleep
    SilentVery occasional subtle noiseOccasional noiseLoud and noisy

    Night sleep
    SilentVery occasional subtle noiseOccasional noiseLoud and noisy

    I use the following to help my child sleep: (check all that apply)
    RockingPattingShushingNursing/bottleBeing heldWhite noiseLovey toyPacifierSwaddlingWalking/movingCar/Stroller rideTVMusicOther

    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?
    12345none

    Do you currently have your child on a set schedule for naps and bedtime?
    yesno

    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
    yesno
    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 backRolling from back to bellySitting upBut can't lay back downCrawlingStanding in Crib

    Any other information you would like to share?

    I have read and understand the Healthy Care Practitioner and Liability/Disclaimer (required)