Sleep Coaching: Family Info & Sleep Questionnaire

Sleep Coaching: Family Info & Sleep Questionnaire:

Sleep Coaching: Family Info & Sleep Questionairre

This form is for more detailed family information and needs no identify factors. Please fill in as much as you can. I will also send you a diary to capture 3-5 days of sleep activity so that I can evaluate before our 1st appointment.

POINTS TO NOTE:
Note:
- Please be aware that I do not use any controlled-crying, cry-it-out, or other intensive crying-to-sleep techniques.
- Whilst I never prescribe crying to sleep techniques, are you aware that sometimes children will cry when they do not get the same sleep strategy that they have had up till now, although this will never be on their own.
- Are you ready and willing to make changes?
- Are you planning to be home for the next few weeks and be consistent and patient with your child’s sleep plan?
What day would you prefer to speak?
What time of day would you prefer?
Is there anything you would like me to be aware of to help me to be respectful to you and your family:
BACKGROUND, HISTORY & HEALTH:
Do you have any significant health concerns in relation to your child? If yes, please share:
Is your child taking any prescribed, over the counter, herbal or naturopathic medicines?
Is your child taking any vitamin or mineral supplements?
Who looks after your child during the day?
Are there any concerns regarding your child’s weight?
Does your child have any skin problems – such as dry skin, eczema or rashes?
Does your child have a history of tongue tie?
Does your child regularly mouth breathe/snore/have noisy breathing?
Your child’s stool pattern: How frequently do they open their bowels, and what colour/consistency?
Is your child breast or formula fed?  (If applicable)
Does your child have a pacifier/dummy or suck thumb/fingers?
How was your child born? (Cesarean, ventouse, forceps, unassisted vaginal delivery)
Where there any complications at birth?
Is there a family history of allergy, food intolerance, eczema or asthma?
Is your child currently seeing any other health care professional or alternative/complementary therapist? If so, please specify:
YOUR CURRENT SLEEP SITUATION:
How do you get your child to fall asleep currently?
Do you have a bedtime routine? If yes, what do you do?
Where does your child sleep (your bed, crib, cot, toddler bed etc)?
Is there anything you definitely do not want to change?
Is there something you definitely want to change that you’d like us to prioritise?
How would you describe your parenting style?
How would you scale your current sleep situation?
- I just need some reassurance
- I know my child's sleep is normal, but I'm beginning to struggle and need some support. I do not really feel I need to change my child's sleep, it's more how I manage on a day to day basis
- I'm beginning to find my child's sleep problematic, and need to find some ways to make it easier. I am prepared to make some changes, but do not feel this is an emergency situation, and I can take my time.
- I am in a sleep crisis. I feel like I cannot go on much longer, and urgently need to make some changes. I may not know where to start, and I may not have the capacity for anything that results in even less sleep, but I definitely need to make some big changes in order to cope.
FOOD, FEEDS & EATING:
Please let me know about anything relevant to your child’s diet or nutritional status. If your baby is exclusively milk fed please don’t worry about telling me about timings - I encourage responsive, cue-based feeding.
Please write down your child’s APPROX feed/meal times in 24 hours:
What are the typical day’s meals/snacks types:
Please tell me anything else related to eating that may be helpful to know:
YOUR MAIN SLEEP CONCERNS:
Please tell me if you have any particular concerns about your child’s sleep. You can write as much or as little as you like. Please give a brief overview of your child’s sleep problem/issue and what methods (if any) you have tried so far to alleviate this. Please explain how the problem/issue affects you, your child and the rest of the family.
Naps:
Settling to sleep:
Middle of the night:
Daytime behaviour:
Early rising:
Effect on family:
Tried so far (& roughly when):
YOUR SPECIFIC SLEEP GOALS:
Please detail what your goals are regarding your child’s sleep:
Please add anything else you feel is relevant in your situation:
SLEEP DIARY:
Please keep the following sleep log for 3 days (we can increase to 5 if needed)
Day 1:
Date:
Time woke in morning:
Time & length of nap(s) in day:
Time start preparation for bed in evening:
Time went to bed in evening:
Who put him/her to bed:
Time went to sleep:
Time(s) woke up in night:
What happened and what did you do:
Day 2:
Date:
Time woke in morning:
Time & length of nap(s) in day:
Time start preparation for bed in evening:
Time went to bed in evening:
Who put him/her to bed:
Time went to sleep:
Time(s) woke up in night:
What happened and what did you do:
Day 3:
Date:
Time woke in morning:
Time & length of nap(s) in day:
Time start preparation for bed in evening:
Time went to bed in evening:
Who put him/her to bed:
Time went to sleep:
Time(s) woke up in night:
What happened and what did you do:
PLEASE MESSAGE JAY ONCE YOU HAVE COMPLETED THE DIARY.
Send a message to let Jay know that the questionnaire is finished, or if you have any questions. This will need to be done at least 48 hours before the first consultation to give Jay a chance to evaluate the sleep diary.
Name
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Sleep Coaching: Family Info & Sleep Questionairre

POINTS TO NOTE:

BACKGROUND, HISTORY & HEALTH:

YOUR CURRENT SLEEP SITUATION:

FOOD, FEEDS & EATING:

YOUR MAIN SLEEP CONCERNS:

YOUR SPECIFIC SLEEP GOALS:

SLEEP DIARY:

Day 1:

Day 2:

Day 3:

PLEASE MESSAGE JAY ONCE YOU HAVE COMPLETED THE DIARY.

Share this: