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Sleep History Form
Sleepy On Hudson
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Email
*
Your email
Parent's Name:
Your answer
Parent's Name:
Your answer
Child or Children's Name:
Your answer
Child's Age:
Your answer
What is the best way to reach you?
Your answer
Parent's Occupation:
Your answer
Address:
Your answer
How did you hear about Sleepy On Hudson?
Your answer
Any problems during pregnancy and/or labor?
Your answer
How are you feeling physically, emotionally overall?
Your answer
Any medical concerns for child?
Your answer
Pediatricians name:
Your answer
Has your Pediatrician ruled out any medical problems that may be causing your child's sleep problems?
Your answer
Is your child breast fed, formula fed, or both?
Your answer
Does child use a pacifier?
*
Yes
No
Does your baby take a bottle, sippy cup, or straw cup?
Your answer
Where does your child sleep, are you happy with this, and Are both partners in agreement about this?:
Your answer
If you have other children, how do you balance bedtime? Is there room sharing, is that a goal?:
Your answer
Daytime schedule - take us through a typical day, even if every day is different, give us your best description of what tends to happen. Include wake up, feedings, naps, and bedtime routines.:
Your answer
Bedtime and night wake ups - take us through what happens at bedtime and how the rest of the night tends to unfold. What do you do when your baby wake ups, how do you respond, and finally when is your child up for the day?:
Your answer
What does your child’s sleep arrangements look like? (Ex: sleeps in own room)
Your answer
How do you get your child to sleep for naps, bedtime, and during wake ups?:
Your answer
How long does it take your child to fall asleep?:
Your answer
Does your child have or did they have reflux?:
Yes
No
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Describe your child's temperament.:
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What is the ultimate outcome you and your partner would like to see with regard to your child's sleep habits?:
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Please make any additional notes or remarks that you would like us to consider before we meet.:
Your answer
Does your child snore, sleep restlessly, have night terrors, or sweat while sleeping?:
Your answer
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