Sleep History Form

HISTORY FORM FOR SLEEP SUPPORT

Please complete and submit this form at least 24 hours prior to your consultation. Please also complete this in one sitting and on a computer rather than a mobile device.
Parent Information
Parent #1*

First NameLast Name
E-mail*
Don't worry, we're not going to spam you.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number for Follow-Up Calls*

Area CodePhone Number
Parent #2

First NameLast Name
Parent #2 E-mail
Don't worry, we're not going to spam you.
Phone Number, if different than above

Area CodePhone Number

Pediatrician Information
Pediatrician's Name*

First NameLast Name
Practice Name*
Pediatrician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your pediatrician ruled out medical uses that may be causing or contributing to your child's sleep problems, and have you specifically asked if we can move forward with sleep learning?*

YesNo
I recommend you have this conversation in advance of our meeting.
Please detail their recommendation.
Does your pediatrician believe your child "should" be able to sleep through the night given his/her age, weight, and medical health? If you are unsure, please discuss this with your pediatrician in advance of our meeting. Ask, specifically for your child's age, health, etc. how many hours is realistic to go without eating overnight. If you have discussed this, please detail their recommendations here. Note- We do not need to jump to reducing or eliminating night feeds but we do need to know what we can work toward. *
Child's current weight and percentile, if known.
Are there any current concerns about your child's growth or, if breastfeeding, their latch or your supply? *

Sleep Environment
Think about your child's sleep environment. List here anything else that factors into it such as a crib "aquarium", a star projector, a mobile, the DockaTot, the Snuggle Me, a crib wedge, a Wubannub, etc.*
Does your child sleep in a crib, bed, bassinet, swing, rock and play, etc and in your room, with a sibling, or in their own room? If they start in one location at bedtime and move to another overnight or if you are using a combination of devices, please detail that in your response. If they sleep in their/your room at night but anywhere in the house during the day, please detail that in your response. *
Are you planning to work on sleep in the current room or is there another room you are hoping to move your child to?*
What does your child wear when sleeping? If you are using a sleep sack, sleep suit, swaddle or anything similar, please include that in your response. *
What is the most recent milestone your child has mastered and at what age? For example, rolling, crawling or walking.*
Any past or current medical issues and are these currently resolved or well controlled? **
Does your child snore or mouth breathe (consistently not just when congested), fall out of bed often, or sweat excessively during sleep?
Are these sleep issues new or ongoing?*

NewOngoing
When did they begin?
Please outline your child's 24 hour schedule including average clock times for waking, napping (also average nap lengths) and bedtime as well as nursing sessions/bottles or meals. If dropping off and picking up siblings impacts your child's schedule, please include those times as well.*
Is your child home each day?*

YesNo
If daycare, grandparents, a nanny/regular babysitter, or anyone else factors into your child's daily life and schedule, please detail that here.

Sleep Routine
How do you decide when it is time for your child to nap or go to bed? Are you watching the clock and, if so, what times are you aiming for? Are you watching how long your child has been awake and, if so, how long is the typical max spent awake?*
How does your child seem leading up to nap and bedtime attempts? Normal, wired, tired, hyper? What cues are they showing that tell you it is time to attempt to get them down?*
Pretend you were introducing your child to me as a little person, without respect to sleep struggles. What words would you use to describe them? For example strong-willed, social, hyper, easy going etc..*
Please describe the steps involved in getting your child to sleep currently at bedtime and for naps (if naps are different). Think of painting a picture with words so I can feel like I am there with you. Detail the things you do in the order in which you do them from the time you enter the room to the time your child is asleep.*
How long does it take your child on average to fall asleep?*
Please describe how often your child wakes overnight and walk me through what you do each time your child wakes. If milk of any kind factors in (breast, bottle or cup), please include how often and the minutes or ounces of each. Again, paint a picture with words so I have a sense of exactly what is happening.*
If your child is nursing or taking a bottle overnight, what is your goal here? Do you want to work toward less overnight feeding (and, if so, how many times feels sustainable and reasonable to you) or is your goal zero feeds? Again we will not necessarily jump from one to the other abruptly.
What state is your child in when you place them in their crib/bed and when you step out of the room?

Wide awakeDrowsyFully asleep

Sleep Goals
What are your concerns about your child's sleep?*
What are your concerns about this process and implementing a plan together?*
What are the goals you want to achieve together?*
What strategies have you already tried to resolve these issues and with what result?*
We will cover many options for reaching your goals. Before we do, are you generally of the mindset of making small, gentle changes over a longer period of time (current situation feels fairly sustainable for a bit longer) or are you of a mindset of reaching your goals as quickly as possible even if that means that the process feels a bit more intense (current scenario feels very unsustainable and everyone is at a breaking point)?*
Are you planning any major events or changes in the weeks ahead: returning to work, travel, guests, introduction of a new caregiver, moving, arrival of a new baby, potty training, etc.?*
How did you hear about Confident Parenting? If a friend, neighbor or colleague sent you, please include their name so I can thank them and gift them a free phone call!*
Should be Empty:

HISTORY FORM FOR SLEEP SUPPORT

Parent Information

Child Information

Pediatrician Information

Sleep Habits

Sleep Environment

Sleep Routine

Sleep Goals