Sleep Intake Questionnaire

Parent/Guardian Name

Your email

Your Phone Number

Child’s Name

Child’s Date of Birth

Pediatrician

Sleep Environment

Where does your child currently sleep?

Does your child share a room with anyone?

Describe the sleep environment (noise machine, nightlight, temperature, etc.):

Any sleep devices/props used? (pacifier, rocking, feeding to sleep, etc.):

Daily Routine

Morning wake time:

Number of naps + times/lengths:

Nap routine (location/how they fall asleep):

Bedtime routine:

Typical bedtime:

Nighttime Sleep

Average number of night wakings:

What happens during these wakings?

Length of wakings:

How does your child wake? (crying, fussing, calm):

Feeding

Feeding method(s):

Daytime feeding schedule:

Night feedings (frequency + amounts):

Health & Development

Any medical concerns/allergies:

Recent illnesses/regressions:

Milestone progress:

Teething currently?

Sleep Challenges

Main sleep concerns:

How long have these been occurring?

What have you tried already?

What worked/not worked:

Family Goals

Top 3 sleep goals:

What does success look like for your family?

Any Additional Information: (optional)