Infant Sleep Form

INFANT SLEEP QUESTIONNAIRE

* Indicates required field

Parent's Name *

First

Last

Email *

Child(ren) name(s) and age(s): *

Partner's Name (if applicable) *

First

Last

Describe your challenges with regards to sleep specifically: *

Please share what issues (if any) have arisen out of the above challenges: *

Describe your successes thus far with regards to sleep: *

How do you get your child to sleep for naps and bedtime? *

Where does/do your child/children sleep? Do you have any concerns about “bed-sharing”or bedding close to your child/children? *

Describe a current typical “day in the life” of you and your child/children *

Please briefly share your Birth Story, including location of birth, duration of labour/delivery, any complications or trauma, and your feelings about the birth: *

Are you currently nursing? *

Please share your child’s typical diet in an average day: *

How many cups of coffee or caffeinated tea do you drink per day on average? *

Do you think there is any additional information that would be helpful for me to know? *

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INFANT SLEEP QUESTIONNAIRE

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OLYMPIA, WA

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