Questionnaire Baby 0-30 Mths | WeeWellness Inc.

Client Questionnaire - Baby (0-29 months)

We understand that you may find this form long, but all the questions are an important part in the development of your customized sleep plan and getting your little one to sleep.

Please answer the below questions in the spaces provided and hit SUBMIT when completed. The information on this form is needed 48 hours prior to your initial meeting with your Dream Team Consultant. If you have any questions, please email us at child.sleep@wee-wellness.com.

GENERAL INFORMATION

Names of Parents

Child's Name

Child's Birthday

Month

Day

Year

Child's Gender

Address

City

State / Province

Zip / Postal Code

Country

Phone

Email

1. Child's Current Weight (in lbs.)

2. Was your child born prematurely?

If yes, how early?

3. Does your child have any current or previous medical issues (including colic, reflux, food or environmental allergies, etc.)?

If YES, please describe. Include if issue(s) was/were diagnosed by a medical professional. If NO please enter "N/A"

4. Does your child take any medication?

If YES, what medication(s)?

5. Have there been any other health issues or concerns not mentioned above?

If yes, what are they?

6. Have you spoken to your doctor about your child's sleep difficulties?

7. What are your daytime childcare arrangements? Check any that apply

CHILD'S CURRENT SLEEP HABITS

8. Please describe your child's DAYTIME sleep, including WHERE naps occur, NUMBER, TIMES, and TYPICAL DURATION of naps, and any ROUTINE you use for naps, if applicable. If your child no longer naps, please write "N/A".

10. Does your child use a pacifier to sleep?

11. Does your child use a pacifier at other times outside of sleep?

12. What does your child wear to sleep in at bedtime?

13. Please describe your child's NIGHTTIME sleep environment(s) in as much detail as possible (e.g., in own room/with sibling/in parent(s)'s room, in a crib/swing/bassinet/bed, blackout curtains, how bright/noisy their room is, sound machine, etc.)

14. Do you use (or have) a baby monitor in your child's sleep environment?

15. What time do you typically start your bedtime routine?

16. What time do you typically try to put your child to bed each night?

17. Approximately how many times/how often does your child wake in the night? If not applicable, please write "N/A".

18. If your child typically wakes 1 or more times in the night, please check any thing(s) you do to help them return to sleep. Check all that apply

Give them some time to return to sleep on their own

Nursing to sleep

Bottle to sleep

Offer pacifier

Bouncing/rocking/patting/touching to sleep

Music, singing, talking to sleep

Sitting/lying with them while they return to sleep

Bedsharing (parent/caregiver sleeps in child’s bed or child sleeps in parent's/caregiver’s bed)

Other

19. What time does your child typically wake in the morning for the day?

CHILD'S DEVELOPMENTAL MILESTONES AND TEMPERAMENT

20. Please describe your child's eating habits - are they exclusively bottle-fed, breast-fed, both? Have solids been introduced?

21. How many feeds does your child typically have per night? If none, please write "N/A".

23. Is there anything else about your child that your feel is important for your Sleep Consultant to know?

PARENTING STYLE AND PREFERENCES

24. Have you previously used any sleep training methods or programs to get your child to sleep better?

If YES, please briefly describe the method/program and the outcome.

25. Describe how your child's current sleep challenges are impacting your life and how it makes you (and any other caregivers who are impacted) feel?

26. Please provide, in detail, any additional information that will help your Sleep Consultant understand what's going on with your child's sleep troubles. If you have specific questions, you can include them here, too.

GOALS AND NEXT STEPS

27. If you were to imagine your ideal vision of sleep for your family, what would that look like? In other words, what are the goals you'd like your Sleep Consultant to help you with?

28. What is the ideal time for your child to wake in the mornings (even if they are not achieving it now)?

29. What is an ideal bedtime for your child at night (even if they are not achieving it now)?

30. If your child still feeds during the night, do you have any goals relating to this?

31. Are there any roadblocks you can foresee that may inhibit progress - either personally (one parent/caregiver is impatient or easily frustrated), schedule-wise (daycare, work schedules, appointments) etc.?

32. Do you have a target date in mind to start to implement your Sleep Plan? If not, enter today's date and your Sleep Consultant will begin working on a custom Sleep Plan right away.

33. Is there anything else you feel is important for you Sleep Consultant to know or that you would like to share?

New Program Information

Client Questionnaire - Baby (0-29 months)

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