Older Child
Client Questionnaire

About your Child

Child's First Name

What is your child's age?

Names of Parents and any other caregivers?

Name and age of any siblings

Is your child on any medication?

Yes

Are there any health concerns?

Is your child on any medication?

Yes

If so, what for?

Have you spoken to your doctor about your child's sleep difficulties? If so, what information can you provide that will help in determining the best sleep plan for your child?

What time does your child wake up to start his/her day?

What happens at this time? Are they given a bottle, breastfeed, start solids, etc?

What signals do you notice your child gives when he/she is tired?

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 the first nap?

How long does the nap last?

What time does the second nap occur?

How does your child fall asleep for this nap?

How long does the nap last?

Is there a third or fourth nap during the day or early evening?

Yes

How does your child fall asleep for these naps?

What time do you start getting your child ready for bed?

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?

What happens during the night? (Best and Worse Case Scenarios)

Have you read any books about infant sleep and have tried any suggestions from these books in the past?

Was there a time when your child slept well and then things changed?

Yes

If so, explain.

What is your number one goal while implementing your sleep plan?

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

Thanks for sharing! We always strive to improve.

Older Child Client Questionnaire

About your Child

Older Child
Client Questionnaire