Sleep Questionnaire
Please provide as much information as possible. This helps me to prepare for our consultation.

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Email *
Parents' Names & Surnames *
Cell number *
Preferred language
Your child's name
Your child's gender
Child's birth date
Child's age
Child's birth weight
Child's current / most recent weight (if known)
Do you have other children?
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If yes, please specify their ages
Describe your child's health
Describe your child's temperament
Are your child's milestones on track?
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Tell me about your child's eating / feeding
If breastfed, describe the general pattern?
If formula / expressed milk, how many bottles x ml in 24h?
If on solids, how many meals a day?
Describe your child's daytime care
Where does your child usually sleep (when at home)?
Type of bed
What time does your child's day start?
Please give approximate TIME and DURATION for all daytime NAPS
How does your child usually fall asleep at NAP time? (you can mark more than one answer)
How long does it normally take your child to fall asleep at NAP time?
Any additional comments about NAP time?
BED time is at approximately what time?
How does your child usually fall asleep at BED time? (you can mark more than one answer)
How long does it normally take your child to fall asleep at BED time?
Any other comments about BED time?
How many times does your child wake most nights, on average?
What does your child usually need to fall asleep again?
How long is he/she awake each time?
What do you feel is the main issue / problem?
Any comments you would like to add?
Describe your general parenting philosophy
What advice regarding sleep have you tried? (What worked, what didn’t work?)
Have you received advice from your paediatrician regarding sleep?
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If so, what was the recommendation?
How do you feel about this advice?
Anything else you would like to add - any other issues that you suspect could affect your child's sleep?
Any particular questions that you would like to discuss?
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