Toddler/Child Questionnaire
Please take the time to answer some questions about your child to help me prepare for our meeting. It will allow us to make the most of our time together.
Please complete this questionnaire at least two days before our meeting. Thank you!
About your Child:
What is your child’s name & pronouns?
Your child's date of birth:
Names of parents and/or caregivers & siblings
Please provide your mailing address
Please provide your phone number:
Has your child had any health issues or concerns?
Is your child on any medication I should be aware of?
What would an average day of food consumption look like?
How would you rate your child’s eating habits? (picky eater, healthy appetite)
What time is dinner? Does your child have any snacks right before bed?
Are there any developmental delays or concerns about your child?
Are there any behavioral issues or concerns?
Does your child attend daycare, school, or stay at home?
Are there any concerns with your child’s communication skills?
How does your child respond to instruction and boundaries from you and/or others?
How does your child handle transitions from one activity to another?
How does your child respond to stress?
When and where does your child play or watch any sort of electronic devices?
Sleep Environment and Sleep:
Describe your child's sleep environment (dark? night light? clock?):
Where does your child sleep (toddler bed, crib, co-sleep, room-share)?
Does your child snore or are they a heavy mouth breather?
What time does your child start the day?
What happens when they wake? Are they given a bottle, breastfed, solids?
Does your child ever take a daytime nap? If so, when and where?
How does your child fall asleep for their nap?
How long does the nap last?
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?
What time are they 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?
About you:
What are the most challenging issues for your around your child's current sleep situation?
What is your number 1 sleep goal for your family?
What is your parenting style/philosophy?
Are there any concerns or worries about getting your child to sleep well?
Is everyone in the household committed to seeing your child sleep well and on their own?
Is there anything else you’d like to share with me that you think I should know before we meet?
How did you hear about Plume Sleep? Please let me know if you were referred!
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