Sleep Questionnaire
The following questions are designed to obtain a detailed history of your child’s specific sleep problems. Even if parts of your daily routine do not seem important to you, please include them as asked, as they may prove to be an important part of the overall picture. If you have multiple children, please fill out information for all children involved.
1)How old is/are your child/ren?
2)What is your child’s name?
3)Who else lives in your home? Please include everyone, even if they do not live there full-time.
4)Is your child breastfed or bottle fed?
5)If bottle fed, does your child receive formula, breastmilk, or something else?
6)Is your child fed on demand (cue feeding) or on a schedule?
7)How often does your child eat?
8)Does your child receive any solid foods or foods other than milk/formula? How often and what are they?
9)Where does your child sleep? Please be specific and include all sleeping arrangements as children often sleep in multiple places throughout the day and night (i.e. may start out in crib, but ends up in parent’s bed).
10)Do you co-sleep and what are your beliefs about co-sleeping?
11)What are your concerns regarding your child’s sleep?
12)How often does your child have bowel movements?
13)Does your child have a persistent cough, especially at nighttime or while sleeping?
14)Does your child ever wake up crying? If so, is he/she easily comforted?
15)Does your child have any medical problems that you are aware of?
16)Does your child have any type of rash?
17)When was your child’s last illness (cold, earache, stomach flu, etc)?
- What was it?
- What were the symptoms?
- How long did it last?
- What treatments, if any, were used?
18)Is your child taking any over-the-counter (OTC) medications/remedies, or any herbal or prescription medications? If yes, what for?
19)Has your child experienced any stressful events recently such as moving, death of a loved one, divorce, new school or daycare, etc? Please answer even if your child is an infant.
20)Are you experiencing any stress or anxiety? What about?
21)Do you have any history of depression/anxiety or postpartum depression? If yes to either, are you on medications for this?
22)Did you experience any difficulty getting pregnant?
23)Have you had any previous miscarriages?
24)Did you have any trouble breastfeeding (if applicable) in the beginning? If so, please elaborate on the specific issues and how you dealt with them (lactation consultant, switched to formula, etc).
25)When did your child’s sleep problems begin?
26)How often do they occur (nightly, weekly, etc)?
27)Does your child have a set bedtime?
- If so, what is it?
- If not, when does your child usually go to sleep (please include a full time range, for example, “sometimes at 8 pm, sometimes not until 10 pm).
28)Do you have a bedtime routine? If yes, what is it (be specific and include times)?
29)Does your child nap during the day?
- If yes, how often (once a day, twice a day? Every day vs few times a week)?
- How long are the naps?
- Is there a set naptime, or is it whenever your child seems tired and sleepy?
- Is naptime a struggle?
- What are total hours of napping your child usually gets per day?
30)How many hours does your child sleep at night (include total hours of nighttime sleep, even if your child wakes frequently).
31)Does your child wake up at night? How often?
32)Does your child snore or have noisy breathing?
33)Does your child seem restless once asleep?
34)Does your child have any behavioral issues during the day such as irritability, aggression, frequent temper tantrums, etc? Any behavioral or academic concerns (if applicable)?
35) Who watches your child during the day? Please be specific since many children have multiple caregivers throughout the week.
36) What are your goals for your child’s (and your own) sleep?
37)What books and/or methods have you already tried for improving your child’s sleep?
38)How did you hear about BabyMuse?