Intake Form Jennifer 2016-11-10T18:56:49+00:00

Parent's Name(s) (required)

Cell Phone (required)

Alternate Phone

Email (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

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)