Questionnaire

Please pick the appropriate questionnaire age group below by toggling and then submitting your questionnaire and I will email you, within 24 hours.

Questionnaire - 0-18 Months

Questionnaire – Baby

Hi,

I’d like to ask you to take a few minutes to answer some questions about your child’s sleep habits before we talk in person.

This will help me prepare for our meeting, and will let us make the best use of our time together.

There are quite a few questions, but almost all of them can be answered in just a sentence or two, so please don’t be intimidated!

You can just answer the questions in the spaces provided, and then send this attachment back to me at email hidden; JavaScript is required . It would be great if you could have this back to me at least 2 days before our meeting!
Thanks, and the questions start below!

0 - 18 months

Select Package

What is your child's name?

Parents name?

Physical address for Epimax delivery?

Name and telephone number of person receiving the parcel?

How old is your child?

How much does he / she weigh?

Was your child premature?

Yes

Did he / she have colic?

Yes

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

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

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

Please fill out the form and send it before purchasing a package.

Add to basket

NiteNurture
R3999,00
Add to basket

Restful Nights Coaching
R2999,00
Add to basket

Restful Nights Coaching After Hours (including Saturday)
R3499,00
Add to basket

SleepSerene
R2299,00
Add to basket

SlumberGuidance Pro
R1600,00

Questionnaire - 18 Months - 5 Years

18 months - 5 years

General

Select Package

What is you address for the Epimax delivery?

Name and telephone number of person receiving the parcel?

Phone Number

What is your child’s name?

Age and date of birth of your child?

Names of parents and any other caregivers?

Name and age of any siblings?

Are there any health concerns?

Is your child on any medication?

Does your child have any food allergies or sensitivities?

Yes

Other

How would you rate your child’s eating habits? (picky eater, healthy appetite, only eats the same 5 things..)

Picky eater

Healthy appetite

Only eat 5 foods

Other

How much juice or milk does your child consume in a day?

What is for breakfast, snacks, lunch, dinner and treats?

What time is dinner?

Does your child have any snacks right before bed? If so, what?

Are there any developmental delays or concerns about your child?

Sleep Questions

What time does your child start the day?

5am

6am

7am

8am

Later

Other

Does your child snore or is he/she a heavy mouth breather?

Yes

Other

What happens when he/she wakes up in the morning? (Feeding, play, cuddles, breakfast)

Where does your child sleep, and do they share a room with anyone?

Sleep in his/her own bed in their own room

Sleep in his/her own bed in our room

Sleep in our bed then moved to his/her own room

Sleep in our bed all night

Sleep wherever they fall asleep

On a scale of one to ten, with ten being extremely dark, how dark is your child’s room at bedtime and through the night? (1 being the lightest, 10 being darkest)

Where and when does your child watch TV?

In the living room in the evenings

In the living room any time of day

In the living room before bed time

In the living room but not before bed time

In our room anytime of day

My child does not watch TV

Where and when does your child play on any other sorts of electronic devices?

Everyday anytime he/she wants to

Everyday anytime he/she want to but with limits

Does your child ever take a daytime nap? If so, when and where? How long is the nap?

What time do you start the bedtime routine?

What are the steps of the routine?

What is the scenario when your child is falling asleep?

Every night is different

We prepare the room, prepare the bath and plan ahead

We try to plan ahead but have no routine

Other

What time is he/she actually asleep?

What happens throughout the night? Best and worst-case scenarios?

Was there a time when your child did sleep well, and things changed?

What are the most frustrating or difficult issues for you around your child’s current sleep habits?

He/she is crying at bedtime

He/she does not want to fall asleep on his/her own

He/she does not sleep through the night

He/she wakes at night

He/she throw tantrums at bedtime

We dont have many frustrations

What would be your number 1 sleep goal?

For my child to sleep through the night

For us to have a well rested night

For us to successfully have a bedtime routine

Has your family experienced any major life changes or traumas that could be affecting your child?

Is there a family history of depression or anxiety disorders?

Are there any concerns or worries about getting your child sleep well?

Is everyone in the household committed to seeing your child sleep well and on his/her own?

Yes

Other

Is there anything else you’d like to share with me that you think I should know before we meet?

Thanks for getting this back to me, and I look forward to our meeting!

All the best,

Marijke Coetser

Questionnaire Toddler – Young Child

I’d like to ask you to take a few minutes and answer some questions about your child before we talk in person. This will help me prepare for our meeting, and will let us make the best use of our time together. There are quite a few questions, but most can be answered in just a word or two, so please don’t be intimidated.

Answer the questions below in the space provided and then send the document back to me at least 1 to 2 days before our meeting. My email address is email hidden; JavaScript is required

Please fill out the form and send it before purchasing a package.

Add to basket

NiteNurture
R3999,00
Add to basket

Restful Nights Coaching
R2999,00
Add to basket

Restful Nights Coaching After Hours (including Saturday)
R3499,00
Add to basket

SleepSerene
R2299,00
Add to basket

SlumberGuidance Pro
R1600,00
Add to basket

Toddler Slumber Adventures
R2599,00

Please pick the appropriate questionnaire age group below by toggling and then submitting your questionnaire and I will email you, within 24 hours.

Questionnaire - 0-18 Months

Questionnaire – Baby

NiteNurture

Restful Nights Coaching

Restful Nights Coaching After Hours (including Saturday)

SleepSerene

SlumberGuidance Pro

Questionnaire - 18 Months - 5 Years

Questionnaire Toddler – Young Child

NiteNurture

Restful Nights Coaching

Restful Nights Coaching After Hours (including Saturday)

SleepSerene

SlumberGuidance Pro

Toddler Slumber Adventures

There’s an easy way!

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