Sleep questionnaire

Sleep Questionnaire

Your first name *

Your surname *

Relationship to child: (mother, father, grandparent) *

Child’s first name *

Your email address *

Your phone number (mobile) *

Does child have any siblings? (name and age)

Who looks after the child for biggest part of the day? (mother, father, grandparent, nanny, nursery)

Father's name of child

Child’s details

Date of birth *

Due date *

Current age *

Birth weight *

Birth length *

Current weight *

Is child gaining weight? *

Current height *

How old was the child when he/she smiled socially for the first time?

Does child snore?

Does child have any health issues or allergies? *

Your child’s sleep information

Where does your child sleep during the day? (cot, crib, Moses basket, your bed, sling?) *

Where does your child sleep during the night? (cot, crib, Moses basket, your bed, sling?) *

Where do you wish for you child to sleep during the day? (cot, crib, Moses basket, your bed, sling?)

Where do you wish for you chils to sleep during the night? (cot, crib, Moses basket, your bed, sling?)

Do you sleep in the same room as your child at night? *

Do you want to continue to share the same room for night sleep?

How is your child cover while sleeping (swaddled, sleeping bag, blanket or duvet?)

Does your child use any sleep aids (thumb, dummy, plush toy, lovey, breast)

Describe a room where your child sleeps (light, noise, lots of toys etc.)

Does your child sleep in a pram or sling (carrier)? If yes, how often (per week) and when?

Describe your child’s daytime naps (length, quantity, time)

How do you settle your child for daytime naps? (routine and way of settling) *

How do you currently settle your child for night sleep (routine and way of settling)? *

What time do you settle your child for night sleep?

What time does your child wake up in the morning?

On average how many times does your child wake up during the night? In what time intervals? *

Does your child wake up during the night? If yes, how do you settle her/him back to sleep and how does he/she fall asleep? *

Does he/she wake up regularly at the same time?

Milk and your child’s nutrition

Is your child breast fed or bottle fed? Please specify the amount (if bottle fed) or length (if breast fed) How many times per day does hes/he drink milk? *

Does your child eat solids? If yes, please specify how many times a day, at what time and what does he/she eat. *

Child’s temperament

Please answer following questions about your child and hisher temperament. It is very important for me so I can recommend suitable methods in line with your child’s temperament. Try to avoid neutral answers (something in between).

Describe your child’s temperament (calm, active, restless etc.)

MILSTONES

Which of these milestones has you child reached? (yesno)

Lifting his/her head (for new born)? *

When did he/she reach it? *

Rolling over from back to tummy? *

When did he/she reach it?

Rolling over from tummy to back? *

When did he/she reach it?

Sitting? *

When did he/she reach it?

Crawling? *

When did he/she reach it?

Crawling on all fours? *

When did he/she reach it?

Standing up? *

When did he/she reach it?

Standing on his/her own? *

Walking? *

When did he/she reach it?

How active is your child?

Is your child predictable? Can you predict his/her hunger and tiredness, mood and so on?

How does your child react to strangers? Is he/she more of a mummy’s type or, I like to be held by everyone and it is fun? ‘

How does your child handle changes? Changes in regime, game, places, vacations and so on?

Is your child very sensitive or more phlegmatic?

How difficult is to make your child angry? When he/she gets angry does it last for a long time or is it just a bit of crying and he/she is calm again?

Is your child easily distracted? If he/she is for instance hungry, can you distract him/her easily? Or if hes/he gets hurt can you distract him/her from the pain?

Can your child play with one toy for a longer time or does he/she prefer to change toys more often?

What is the best way to calm down your child? When he/she is crying what works for him/her even if just for a short while? (please answer yes – no)

Singing *

Cuddles *

Clapping *

Rocking in your arms *

Rocking on gym ball *

Breastfeeding *

Water drinking *

Your issues and goals

What do you consider to be your childs sleep problem? *

What would you like to achieve? What is your goal?

You can have more goals.

Where would you like your child to sleep during the day?

For example: pram, cot, sling - if it is not supposed to be the cot, then choose a way that you prefer which guarantees enough sleep for your child – otherwise I recommend the cot

Parents description and their temperament, opinions

Please shortly describe your parenting style. (flexible, rigorous)

What type of parent are you? Patient, inpatient?

How do you feel about your child’s cry?

Do you and your partner agree on sleep coaching? What is hisher opinion on sleep consulting?

Can we include your partner in sleep consulting programme?

Have you ever tried to teach your child to settle on hisher own? If yes what method did you use? How did it go and what was the result? How old was your child at that time?

Do you prefer shorter method of sleep settling help or a longer technique that requires you to be more patient and takes longer (14-20 days approximately)?

Questions about mummy

Is mummy pregnant at the moment?

Does mummy suffer from postnatal depression? If yes, is she taking any medicine?

If you are breastfeeding: do you take any medicine?

How did you find out about me?

Please describe below your current 3 days. Please fill in time, sleeps, feedings with milk or solids (if applicable), bath time and everything you consider to be important. Example: 06:00 getting up and breastfeeding 07:00 breakfast 08:30 sleep (30 min) etc.

Day 1

Day 2

Day 3

Are there any other notes or information you would like to share with me to give me more details?

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