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Newborn Sleep Questionnaire

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Household Information

Tell me a bit more about your family!

Question 2 of 71

Parent(s) Name(s) and pronouns (she/her, he/him, they/them):

Question 3 of 71

How do you refer to yourselves as parents? (eg. Mommy, baba, papa, etc)

Question 4 of 71

Your age

A

Under 25

B

25-30

C

30-35

D

35-40

E

Over 40

Question 5 of 71

Name and age of children who live in your household (Place an asterisk next to the child/children whose sleep concerns we will be addressing):

Question 6 of 71

Other caregivers who will be involved in your baby's sleep work (name and relationship to child):

Question 7 of 71

Are the other individuals on board with your plan to address your baby's sleep? (It is crucial that this be discussed before our initial consultation)

A

Yes

B

No

Question 8 of 71

Pediatrician / Family Doctor Contact Info (Name & City)

Question 9 of 71

Have you spoken to your paediatrician or other health care practitioner about your sleep concerns? If so, what did they suggest?

Question 10 of 71

Have you previously worked with a sleep coach? If so, could you briefly tell me about your experience?

Question 11 of 71

Have you read any sleep books? If so, which ones?

Baby's Health History

Let's do a quick screen for any underlying medical issues that could potentially be interfering with your baby's sleep.

Question 13 of 71

Child's Date of Birth

Question 14 of 71

Was your baby born full term (40 weeks)?  If no, how far along in your pregnancy did you get?

Question 15 of 71

Has it been challenging to build your family?

Question 16 of 71

How was your pregnancy?

Question 17 of 71

Were there any complications during labour or in the newborn period?

Question 18 of 71

Has any medical intervention been required for either you or your baby since the birth?

Question 19 of 71

Would you characterize your baby as being "colicky"?

Question 20 of 71

Does your baby have reflux? If yes, has your baby received an official diagnosis or been prescribed medication?

Question 21 of 71

Is your baby taking any medication currently?  (Prescription or over the counter)

Question 22 of 71

What is your baby's current weight? (Please share percentile if known)

Do you or your pediatrician have any concerns about your baby's weight gain?

Question 23 of 71

Does your baby have any allergies?

Question 24 of 71

Does your baby spit up often after a feed?

A

Yes

B

No

Question 25 of 71

Does your baby arch their back or seem to be in discomfort during a feed?

A

Yes

B

No

Question 26 of 71

Does/did your baby have a tongue tie or lip tie?

Question 27 of 71

Do you have a gassy baby?

A

Yes

B

No

Feeding & Airway

Airway

Question 29 of 71

Does your baby have a frequent or constant stuffy nose? (Even if not actively sick)

A

Yes

B

No

Question 30 of 71

Is your baby a restless sleeper?

A

Yes

B

No

Question 31 of 71

Is your baby a mouth breather (at night or during the day)?

A

Yes

B

No

Question 32 of 71

Does your baby sweat during sleep?

A

Yes

B

No

Question 33 of 71

Does your baby breathe loudly or snore while sleeping?

A

Yes

B

No

Feeding & Airway

Feeding

Question 35 of 71

Do you:

(Select all that apply)
A

Chest / breastfeed

B

Bottle Feed (formula)

C

Pump

D

None (weaned)

Question 36 of 71

How has your experience with breastfeeding been so far? (if applicable)

Question 37 of 71

If Breastfed: Do you experience nipple pain while latching or throughout your breastfeeds?

Question 38 of 71

If Breastfed: Have you noticed a compressed nipple shape when your baby unlatches?

Question 39 of 71

If Breastfed: Do you experience burning/throbbing in the nipple or breast after/between feeds?

Question 40 of 71

If Breastfed: Does your baby act satisfied between feeds? Or do you notice constant hands to mouth, an inability to be put down after a period of calm in your arms, or frequent rooting or sucking (such as needing a pacifier) even after a feeding has been finished?

Question 41 of 71

Will your baby only fall asleep when their nervous system is occupied (pacifier, swaddling, in a swing, intense bouncing or rocking)?

Question 42 of 71

Is your baby gaining weight well, and having at least 6 pees and 1 poo per day?

Question 43 of 71

Has your baby started solids?

If so, at what age?

Question 44 of 71

Has your baby started rolling yet?

Question 45 of 71

Has your baby cut any teeth yet? Or do you suspect they are teething?

Sleep Location

Details about where your little one rests their head at night

Question 47 of 71

Where does your baby sleep?

(Select all that apply)
A

Bassinet

B

Crib

C

Bedsharing

D

ON you!

E

In their own room / Nursery

F

In Parents room

G

Other

Question 48 of 71

Please add any detail about your baby's sleep location here.

Does the sleep location change during the night?

Question 49 of 71

If you have other children, do they go to bed at the same time?

Question 50 of 71

Do you worry that your baby's crying may disturb others in your household?

Sleep Specific Questions

Time to get into the nitty gritty!

Question 52 of 71

How would you describe your baby's temperament?

Question 53 of 71

Does your baby suck their thumb or fingers?

A

Yes

B

No

Question 54 of 71

Does your baby use a pacifier?

Question 55 of 71

How long can your baby handle being awake before needing another nap?

Question 56 of 71

How do you get your baby to sleep for naps and bedtime?

How long does it take for your baby to fall asleep?

Question 57 of 71

How do you respond when your baby wakes up at night?

Question 58 of 71

Is there a pattern to your baby's night wakings?

Question 59 of 71

Does your baby appear sleepy during the day but not take a nap?

Schedule / Routine

What does a day in your life look like?

Question 61 of 71

Please outline a typical 24 hour period with your baby, from waking up to through the night. Please include feeding amounts, whether you are nursing or bottle feeding (or both) and times fed.

How are YOU guys doing?

I am here to support your entire family, which includes YOU as parents.

Question 63 of 71

How would you describe your current sleep situation?

A

Sleep is actually fine, we're just ready for some changes

B

Sleep Concern

C

Sleep Emergency

Question 64 of 71

How is your appetite?

Question 65 of 71

Are you able to sleep while your baby sleeps?

Question 66 of 71

Are you having troubling or scary thoughts?

Question 67 of 71

Do either of you feel like you could possibly be suffering from postpartum depression or anxiety? Do you feel "off", not like yourself, in a fog, etc?

Goal Planning

Help me get a good sense of where I can help

Question 69 of 71

What do you hope to learn during our consultation together?

Question 70 of 71

Have you tried anything to address your concerns to date?

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