Questionnaire Toddler 30+ Mths

Client Questionnaire - Toddler (30+ 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 health concerns (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. What time does your child typically wake in the morning for the day?

9. What signals do you notice your child gives when they are tired?

Gets cranky

Stares into space

Pulls ears

Other

10. Does your child sleep in a crib?

If ''No', how old was your child when you moved them out of the crib and what factors led to this decision. (if 'Yes', enter N/A)

11. Does your child use any of the following to sleep in

If ''Other', please specify.

12. Does your child have a favourite "snuggly buddy"?

If 'Yes', does it have a name?

13. What time of day does the first nap usually happen and where does it take place?

15. How long does this nap last?

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

17. What do you do with your child when getting them ready for bed? Please list in order. (For example: bath, brush teeth, sing songs, read stories, play a game etc.)

18. What time does your child actually fall asleep at bedtime?

19. How does your child fall asleep (at this time)?

20. Does your child use a pacifier to sleep?

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

22. What happens during the night? Include best and worst case scenarios

23. Was there a time your child slept well and then things changed? If yes, please describe.

24. Does your child have any siblings? If yes, what are their ages and do they share a room?

25. Do you have a nanny or other caregivers? If yes, what days and times are they with your child?

26. Do you have a furry member (cat, dog, other) of your family who likes to make noise?

27. 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.

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

GOALS AND NEXT STEPS

29. 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?

30. 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?

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

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

32. 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.?

33. 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.

New Program Information

Client Questionnaire - Toddler (30+ months)

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