Name:

Name of child:

Child’s age:

Child's Date of Birth:

What country do you live in?

Where does your child sleep, describe their room?

How many naps a day does your child usually have?

What’s your usual method of putting your child to sleep?

Do they have a white noise machine,night light etc.? If so which:

Do they take a comforter/cuddly toy/blanket to bed?

Does your child use a dummy/pacifier?

What is the temperature in the room (approximately)?

Do they sleep under blankets, in a sleeping bag or other?

Are they light sensitive? (Easily woken by changes in light, light mornings)

Are they noise sensitive? (Easily woken by noise)

Health of child (describe any health problems):

Please describe your child’s sleep problem and how it affects your family:

Have you tried anything before to help correct this?

What’s your child’s bedtime routine?

Roughly what time do they fall asleep?

Can they roll from front to back without help?

How often do they wake in the night and what do you do to get them back to sleep?

What time do they wake in the morning?

Who looks after your child during the day? Childminder, nursery etc.

Regarding your child’s sleep what would you like to achieve?

Does your child eat and feed well?

Is there anything else you think I should know?