Sleep questionnaire
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Email *
Date: *
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I have read, understood and agree with the Terms and Conditions and Privacy Policy *
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I agree for feedback sent to Calm Sleep by email, text or whatapp messages to be published anonymously at calm sleep website and/or social media *
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What is your preferred means of communication? *
Name of child: *
Name of parent/s: *
Child’s date of birth: *
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Was your child born premature? If so, what was the gestational date?
How was your pregnancy and birth?
Names and ages of siblings:
Do you have any significant health concerns in relation to your baby or child?   If yes, please detail bellow:   (e.g. Prematurity, special care baby unit, allergy reflux, congenital health problems, special needs)

Does your child do or have any of the following *when not teething or sick with a known cause*:

Snoring; mucus or blood in the stools; regularly breathing through the mouth; fevers without other symptoms; mouth open most of the day; passing gas regularly at night, sometimes painfully so; rash on the body, eczema, ongoing nappy rash?


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If you answered yes to the above question, please specify which your child has. *
Is your child taking any prescribed, over the counter, herbal or naturapathic medicines?
Is your child taking any vitamin or mineral supplements?
Are there any concerns regarding your child’s weight?
How do you get your child to fall asleep currently? *
Do you struggle to identify your child’s sleepy cues?
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Do you have a bedtime routine? If yes, what do you do? *

When does your child do his/her longest stretch of sleep?

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What happens in the time between dinner and bed time? *
Where does your child sleep (your bed, crib, cot, toddler bed etc)? In the day? At night? *
What is their preferred sleeping position?
Does your child have a dummy/pacifier? *
Does your child snore? *
Is your child currently seeing any other health care professional or alternative/complementary therapist? Please specify. *
Please write down your child’s approx. meal times in 24 hours. (If applicable)
Is you child generally a good eater? What are their favourite meals?
Does your child go to nursery/kindengarden/child minder? How often?
What activities does your child like doing in the day? (tummy time, jumping, massage, swings, quiet play, singing, etc)
Can you tell me a little bit about your child? *
How would you describe your parenting style? *
What feels difficult about the sleep situation? *
Please give a brief overview of your baby’s sleep problem/issue and what methods (if any) you have tried so far to alleviate this. *
Please explain how the problem/issue affects you. *
Please explain how the problem/issue affects your child. *
Please explain how the problem/issue affects your family. *
What feels difficult about your situation? *
Can you please tell me what your goals are from working with me? *
Is there anything that you definitely want us to prioritise for change?
Is there anything you definitely don't want to change?
On a scale from 1 to 10, where is you sleep issue? 1 being very small issue and 10 being a very big issue. *
very small issue
very big issue
Please add anything else you feel is relevant in your situation: *
A copy of your responses will be emailed to the address you provided.
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