Child's Name
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First Name
Last Name
Child's Age
Child's date of birth
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DD
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Gestation at Birth
Contact Phone Number
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Parent(s)' Name(s)
First Name
Last Name
Email Address
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Would you like to receive updates from Whole Baby?
When was your child's last doctor's visit?
Please provide your child's most recent height and weight measurements. When were these taken?
Has your child been growing along his/her curve? If not, when did it change?
Has your child's medical provider expressed any concerns over weight gain or growth? Please describe.
Does your child have any known medical conditions?
Please list any medications your child is currently taking
Has your child been frequently sick?
If so, please describe the nature of the illnesses
How often does your child snore?
Does your child breathe through his/her mouth during sleep?
Does your family have any history of sleep disorders?
How would you describe your pregnancy?
Were there any complications during your pregnancy?
How would you describe your sleep during pregnancy?
Please describe your labour and birth experience? Were there any medical interventions? Was there anything you wish happened differently?
How do you feel about your overall labour and birth experience?
Have you ever been iron deficient? When was the last time you had your iron checked?
When was the last time you had your thyroid checked?
How do you feel about your nutrition since having a baby?
Did your child have any medical issues during pregnancy?
How was the birth for your baby? Were there any complications or separations following birth?
Please check any of the statements that currently apply to you. Please be very honest
Name
First Name
Last Name
Tell us about yourself. What do you consider your strengths and weaknesses? How would you describe your personality?
How are you feeling as a parent?
On a scale from 1-10, how would you rate your current stress level?
Please describe any stress or anxiety you may be feeling
Tell us about your relationship with your child.
How do you practice self care? What types of things do you do that are just to take care of you?
Tell us about your sleep hygiene. What time do you go to bed? What types of activities do you do leading up to bedtime? How are you feeling about sleep?
How were you parented as a child? Are there any positive or negative experiences you remember that have shaped who you are as a parent today?
Are you currently working?
What is your profession?
How many hours per week do you work?
Name
First Name
Last Name
Tell us about yourself. What do you consider your strengths and weaknesses? How would you describe your personality?
How are you feeling as a parent?
On a scale from 1-10, how would you rate your current stress level?
Please describe any stress or anxiety you may be feeling
Tell us about your relationship with your child.
How do you practice self care? What types of things do you do that are just to take care of you?
Tell us about your sleep hygiene. What time do you go to bed? What types of activities do you do leading up to bedtime? How are you feeling about sleep?
How were you parented as a child? Are there any positive or negative experiences you remember that have shaped who you are as a parent today?
Are you currently working?
What is your profession?
How many hours per week do you work?
Tell us about your child. What are their best qualities? What aspects do you find most challenging about their personality?
Is your child extremely sensitive to touch, sound, smell, or light and dark? If so please describe.
Please list the members of your household. Include ages for siblings
How would you describe your approach to parenting?
What is your parenting philosophy?
What outside support do you have as parents? (grandparents, friends, caregivers, etc.)
What external influences do you have as parents? Are you currently feeling any pressure to make changes to any aspect of your parenting?
Who cares for your child during the day? How many hours per week?
Are there any scheduling constraints we should be aware of when building your child's sleep solution?
What commitments do you have outside of caring for your child(ren)?
Have there been any recent changes in your family?
Is there anything else we should know about your family?
How is your child fed? (check all that apply)
If breastfeeding, when was the last time you visited a Lactation Consultant?
If formula feeding, what type of formula are you using?
Is your child currently eating solid foods? If yes, when did they start? What types of food are they currently eating?
Does your child have any allergies or food sensitivities? If so, please describe.
Is there any history of food sensitivities in your family?
Has your child's diet recently changed?
Is your child meeting all their milestones? Please describe some of their recently achieved milestones.
Has your child's medical provider expressed concerns over his/her development?
Is your child currently working on a new skill/milestone? Please describe.
Does your child cry when you leave the room? If so, how do you respond?
Are you or anyone close to your child currently ill or experiencing an emotionally difficult time?
Please describe the amount of time you spend with your child. What types of activities do you do together?
Have you been away from home more than usual or recently taken a family vacation? Please describe.
How do you feel about tears? How do you respond to tears and frustration from your child during the day? Is it a priority to make those tears stop?
If your child is over 9 months of age, have you set any boundaries or limits? How do you do so? How does your child respond when you set and enforce a boundary or limit?
Are you currently using any type of discipline? Please describe.
Please answer the following questions about naps
Where does your child sleep?
What does your child wear to sleep?
Please describe the room in which your child sleeps.
Please select any that your child uses for sleep
Please answer the following questions about nights
Where does your child sleep?
What does your child wear to sleep?
Please describe the room in which your child sleeps
Please select any that your child uses for sleep
Is your child exposed to any artificial light throughout the night?
Describe a typical weekday for your child
Describe a typical weekend day for your child
When your child is not eating or sleeping, what does he or she spend time doing?
How much time per day does your child spend outside?
How much time does your child get per day to freely move and explore (not in a car seat, baby carrier, or high chair)
Does your child have any screen time? If so, please describe what kind, when, and how much
Please describe your current bedtime routine (all the steps you take to prepare your child for bed)
How does your child fall asleep at bedtime? How do you feel during the process?
Please describe your current nap time routine (all the steps you take to prepare your child for naps)
How does your child fall asleep at nap time? How do you feel during the process?
If your child wakes up at night time, how do you respond to him or her? Please describe in detail.
If your child is upset throughout the night, what is the best way to soothe them other than feeding? (Touch, motion, song, etc.)
Do you change your child's diaper at any point throughout the night after putting them down?
Have there been any recent changes to your child's daily routines?
How do you typically start your day with your child?
Do you use the room your child sleeps in outside of sleep? What types of activities? How does he or she respond to the room?
What activites do you enjoy doing with your baby?
What activities help your baby to relax? What activities stimulate your baby?
Have you ever done any sleep training? If yes, please describe in detail your experience, the method used, if you saw any success, if you worked with another consultant, etc.
How many naps does your child take per day?
What time do you get your child up in the morning?
When does your child typically nap?
What time is your child's bedtime?
How long do naps typically last?
Describe a typical night for your child. Does your child wake up throughout the night? When? How often? What steps do you take when they wake up?
What are the main challenges or obstacles with sleep you would like to address?
At the end of our time together, what do you hope to have achieved?
What are your top 2 goals for your child?
What are your top 2 goals for you as parents?
What are your greatest fears about sleep work?
Do you have any plans for travel, obligations, or general limitations in the next month?
How can we help you the most?
Is there anything else we should know?
Please check this box once you have reviewed and completed the entire form.
