For clients

Your sleep questionnaire

Bought a package? Wonderful — tell us all about your little one's sleep so your consultant can prepare your personalised plan before you talk.

0 – 18 months 18 months – 5 years Pre-natal

Sleep Questionnaire — 0 to 18 months

Who sees your answers. Your answers go to MC Sleep Consulting and to the sleep consultant working with you, so that she can prepare your plan. They are not shared with anyone else and they are never sold. They are kept for as long as we are working with you and for a period afterwards in case you come back to us, and then deleted. You may ask to see, correct or delete what we hold at any time by emailing [email protected]. Please do not include anything here that a doctor should be dealing with; if your child is unwell, speak to your doctor or clinic.

Select Package *

Which consultant would you like to work with? *

What is your child's name? *

Where do you live? *

Email *

Phone Number *

Parents name? *

How old is your child? *

How much does he / she weigh? *

Was your child premature? * Yes No

Did he / she have colic? * Yes No

Have there been any health issues or concerns? *

Is your child on any medication? If yes please specify *

Have you spoken to your doctor about your child’s sleep difficulties? *

What time does your child wake to start his/her day? *

What happens at this time? Are they given a bottle, breastfeed, start with solids, etc. *

What signals do you notice your child gives when he/she is tired? * Rubbing eyes Screaming and shouting (tantrum) Yawning Other

Other

What time of day does the first nap usually occur and where does it take place? *

How do you get your child to sleep for this first nap? *

How long does this nap last? * 10 Min 20 Min 45 Min 1 Hour 2 Hours 3 Hours Different every time

What time of day does the second nap occur? *

How does your child fall asleep for this nap? *

Is there a third or fourth nap during the day or early evening? * Yes No

What time do you start getting your son/daughter ready for bed? * 17:00 18:00 19:00 20:00 Later then 20:30

What do you do with your child when getting them ready for bed? (For example: bath, brush teeth, sing songs, read stories, play a game, etc.) *

What time does your child actually fall asleep at bedtime? *

How does your child fall asleep at this time and where? *

What happens during the night? (Best & worst case scenarios.) *

Have you read any books about infant sleep, and have you tried any suggestions from these books in the past? *

Was there a time when your child slept well and then things changed? *

Is your child in his/her own room? And in a crib or bed? * Own room Parents room Crib Own bed

Thanks for getting this back to me, and I look forward to our meeting! All the best, Marijke Coetser

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