Questionnaire

Thank you for choosing us! We offer personalised tailored sleep programs and support to suit each individual family. We know your time is precious but If you could please fill out our simple questionnaire this will help us provide the best support possible for you.

PARENT & BABY NAME: *

SURNAME *

ADDRESS

CITY

PHONE NUMBER

EMAIL *

SEX OF BABY/TODDLER:

Age of Baby/Toddler?

Weight of Baby/Toddler

Was your child premature?

Yes
No

If YES at what gestation?

PLEASE STATE ANY ALLERGIES/MEDICAL CONDITIONS THAT YOUR BABY/TODDLER MAY HAVE (eg Reflux Hip /dysplasia/Milk Intolerances) & LIST ANY MEDICATIONS THEY ARE CURRENTLY ON & IF THEY ARE UNDER GP OR PAEDIATRIC CARE:

IS YOUR CHILD BREASTFED/BOTTLEFED/SOLID FED (one both or all?)

DOES YOUR CHILD SNORE?

HOW LONG HAS YOUR BABY/TODDLER BEEN SLEEPING POORLY FOR? WHAT AGE DID IT COMMENCE?

WHAT TIME DOES YOUR CHILD WAKE TO START THEIR DAY?

HOW MANY NAPS DOES HE/SHE HAVE PER DAY?

HOW LONG IS EACH NAP/SLEEP APPROX?

PLEASE BRIEFLY STATE AN AVERAGE DAILY ROUTINE YOUR HOUSEHOLD WITH BABY/TODDLER?

HOW DO YOU GET YOUR BABY/TODDLER TO SLEEP? (eg Rocking feeding singing patting?)

DOES YOUR CHILD HAVE A COMFORTER OR DUMMY?

EXPLAIN YOUR WIND DOWN TIME/BEDTIME ROUTINE IF YOU HAVE ONE: (eg feed bath bed book)

ARE YOU AWARE OF ANY TIRED SIGNS YOUR BABY/TODDLER MAY SHOW? If yes what are they?

DOES YOUR BABY RELY ON YOU EVERYTIME TO FALL ASLEEP AND RESETTLE/FALL BACK ASLEEP? IF YES HOW MANY MINS DOES IT TAKE?

HOW LONG DOES IT TAKE FOR YOUR BABY TO FALL ASLEEP?

HOW MANY TIMES WILL YOUR BABY WAKE BETWEEN BEDTIME AND MORNING?

ARE YOU GIVING YOUR BABY A DREAM FEED? OR ANY FEEDS DURING THE NIGHT? If yes how many?

PLEASE BRIEFLY STATE AN AVERAGE DAY IN YOUR HOUSEHOLD WITH BABY/TODDLER OR STIPULATE THE ROUTINE YOU MAY FOLLOW: PLEASE DESCRIBE YOUR BABY/TODDLER’S SLEEPING ENVIRONMENT? (eg. own room co sleeping sharing parents room basinet cot etc)

WHAT WOULD YOU LIKE TO MOST ACHIEVE BY UTILISING OUR SERVICES?

What SLEEP SCHOOL program are you interested in?

Email consultation
Phone consultation
Home consultation

ANYTHING ELSE WE SHOULD KNOW?

HOW DID YOU HEAR ABOUT US HERE AT SLEEP SCHOOL?

Questionnaire

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