Infant Intake Form Parent 1 Name * First Name Last Name Email Parent 2 Name First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Child's Name First Name Last Name Child's Date of birth MM DD YYYY Was your child born on their due date? If no, how many days early or late? Child's current age Child's Current Height Child's current weight Child's Sex Currently, what are your greatest sleep challenges? When did you first notice this was happening? Please describe your child's sleep environment (bed type, lights, sounds, temperature, etc.) Please list any medical conditions and medications: When sleeping, does your child? Snore Snore more than half of the time Snore loudly Have heavy or loud breathing Awaken with snoring/snorting sounds Have brief leg jerks or kicks Have restless sleep (tosses and turns, moves around, etc.) Get out of bed at night None of the above Has your child ever stopped breathing at night? If yes, please explain: Have you ever had to shake or move your child to get them to breathe again? If yes, please explain: Does your child sleep in a room alone? If no, please provide details: If in their own room, is the child's door open or closed? Is there a regular bedtime each night? If so, what time? On average, how long does it take for your child to fall asleep? In what position does your child sleep most of the time? Do you notice difficult behavior at bedtime? If yes, please explain: How often does your child wake up at night? What time does your child get up in the morning? Is your child difficult to awaken? Have you ever been awakened by the sound of your child screaming or crying at night? When asleep, does your child bang his or her head on the pillow? Is there a time you need your child to be awake in the morning (for school, daycare, etc.)? Does your child regularly nap during the day? if so, when and for how long? Has your child ever simply stopped his or her activity and taken a nap where they were? Do you swaddle your baby? Has your child ever become weak or unsteady when excited, surprised, or emotional? Does your child have tonsils? If no, when were they removed? How do you (or other caregivers) currently put the baby to sleep? Does your baby have an easier or harder time when put to bed by someone else? Is your baby using a pacifier, lovey, white noise, or other comfort items? How much sunlight is your baby exposed to on a daily basis? Until what hour at night is baby exposed to artificial light? Is your baby breastfeeding, formula feeding, or both? Please list your baby's feeding times, including what he/she eats (including any solids) and how much: Do you believe your baby has colic? Does your baby have reflux or GERD? If so - has it been diagnosed? Was your baby vaccinated? If so, when and which vaccines were given? Has your child recently learned a new skill? (Rolling over, crawling, walking, swimming, etc.) What is your baby's attention span? What is your baby's activity level? How does your baby respond to new sensory experiences? Has your baby developed predictable eating and sleeping patterns? Please describe: How do you feel about crying? Are all caregivers on board with sleep training? How do you feel your child might respond to having you in the room during the sleep training experience? Have you spoken to your child's health care provider about their sleep? If yes, did they have any recommendations? What are your ultimate goals for the sleep training experience? Siblings names, ages, and bedtimes: Is there anything else you think we should know? How did you hear about us? Family or Friend Social Media Pediatrician Other Did you have an ideal start date in mind? MM DD YYYY Thank you!
