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Sleep History Form
Sleepy On Hudson
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Email *
Parent's Name:
Parent's Name:
Child or Children's Name:
Child's Age:
What is the best way to reach you?
Parent's Occupation:
How did you hear about Sleepy On Hudson?
Any problems during pregnancy and/or labor?
How are you feeling physically, emotionally overall?
Any medical concerns for child?
Pediatricians name:
Has your Pediatrician ruled out any medical problems that may be causing your child's sleep problems?
Is your child breast fed, formula fed, or both?
Does your baby take a bottle, sippy cup, or straw cup?
Where does your child sleep, are you happy with this, and Are both partners in agreement about this?:
If you have other children, how do you balance bedtime? Is there room sharing, is that a goal?:
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.:
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?:
What does your child’s sleep arrangements look like? (Ex: sleeps in own room)
How do you get your child to sleep for naps, bedtime, and during wake ups?:
How long does it take your child to fall asleep?:
Does your child have or did they have reflux?:
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Describe your child's temperament.:
What is the ultimate outcome you and your partner would like to see with regard to your child's sleep habits?:
Please make any additional notes or remarks that you would like us to consider before we meet.:
Does your child snore, sleep restlessly, have night terrors, or sweat while sleeping?:
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