Pre-consultation sleep analysis

Helping your child get better sleep

Please feel out all fields of the following form for me to analyze your current sleep situation and prepare recommendations

First and last name

Telephone with country code (for contact through WhatsApp)

City and country of residence

Your child’s name

Your child’s date of birth

On which week of pregnancy was your child born?

How many children do you have in the family and what is their age?

Date of last visit to pediatrician

Are there any medical conditions to take into account?

Weight gain, allergies, breathing issues etc.

Is your child taking any medication affecting his/her sleep?

What does your child eat during the day?

Breastfeeding, formula, other food.

Where does your child sleep?

Own bedroom, own bed in your bedroom, with you in bed etc.

What is in your child’s sleeping zone?

Blanket, pillow, toys etc.

Do you swaddle your little one?

Yes

Does your child use a pacifier during sleep?

pacifier

Yes

How dark is it in the room where your child sleeps on a scale from 0 to 10 (where 10 is total darkness)?

How quiet is it in the room where your child sleeps on a scale from 0 to 10 (where 10 is complete quiet)?

What is the temperature in the room where your child sleeps?

What is the humidity level in the room where your child sleeps?

Describe your bedtime ritual?

What does it start with, finish with, how long does it take etc.

How does your child fall asleep?

During breastfeeding/bottle feeding, by rocking, in your bed next to you, alone in his/her bed.

How many minutes does it take for your little one to fall asleep on average for night sleep and for naps?

Does your child wake up at night? If yes, how often? How long does it take him/her to fall back asleep? How do you help the little one to fall back asleep?

How does your child behave when waking up at night?

Stands up, cries, screams, talks etc.

Are there any night feedings, if yes, how many per night?

From what age does your child have sleep issues?

Describe your day schedule by hours as detailed as possible.

Eg. 6:00 - wake up, 6:30 - breakfast, 8:00-9:00 - first nap, 10:00 - playground etc.

What are your expectations from our work together? What objectives do you set for yourself?

What have you already tried to improve sleep? What has worked and not worked?

Does your partner support your work with a child sleep consultant? Does he/she have any doubts?

Do you have any other questions?

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