Contact Information

Parent Name

Age *

Occupation

Phone *

Address

State

City

Postal code

OTHER MEMBERS OF HOUSEHOLD

Place asterisk (*) next to name of child whose sleep habits you are seeking help for:

Child Name/Age

What is the best place / phone number to reach you in the morning for follow-ups?

What is your e-mail address? *

How did you hear about me, or who referred you?

Have you read either of the Sleep Lady's books? (This is not a requirement but a question that will help your Sleep Coach use your evaluation time more efficiently.)

CLIENT HISTORY

Child's Name

Date of Birth

PRENATAL

Was this a planned pregnancy?

Yes

Any problems during the pregnancy? NO or YES (if yes, please describe)

Delivery/Labor

Vaginal

C-Section

VBAC

Any complications? NO or YES (if YES, please describe)

Any medical problems for newborn at birth? YES or NO (if YES, please describe)

These questions are regarding the Mother

Are you able to sleep at night when your child is sleeping?

How is your appetite?

Are you having any troubling/scary thoughts?

Pediatrician Details

Pediatrician Name

Practice Name

Pediatrician City / State/ Zip

Pediatrician Phone

Pediatrician Street

Would they state that they “should” be able to sleep through the night given their age, weight, and medical health? YES or NO (if NO, please describe)

Has your pediatrician ruled out any medical problems that may be causing or contributing to your child’s sleep problems? YES or NO (if NO, please describe)

DEVELOPMENT AND HEALTH HISTORY

Feeding

Is your child:

Formula-Fed

Breast Fed

Both ٱ Neither/Weaned

Are they using

bottle

cup

both

What percentile are they in?

What is your child’s current weight?