Infant Questionnaire Name * First Name Last Name Email * Phone number * Age of baby * Birth date * MM DD YYYY Baby's name * Date of last paediatrician visit MM DD YYYY Was baby born on due date? If not, how many days early or late? * Baby's height Baby's weight at birth * Baby's weight now Describe the environments your baby sleeps in during the day for naps (cot, pram, car, held) Describe the environment your baby sleeps in during the night (cot, co-sleep, bassinet, held) Does your baby sleep in their own room or in your room at night? Can your child get themselves to sleep during the day? Can your child get themselves to sleep during the night? If they can get themselves to sleep, do they use a dummy, bottle, breast or another sleep aid for this? Do you use white noise? What type of noise is it? What is it played from? Does your child have a comforter for sleep? Does your child use a dummy for sleep? Is the room dark for all sleeps? Describe all layers of clothing for sleep including sleeping bags and if this differs for day and night Do you use a heater/air-conditioner for warmth/cooling? If so, what type and what do you use? What position does your child sleep most of the time? Tummy/back/side What age did you discontinue swaddling your child or are they still swaddled? Average number of night wakings? How do you get them back to sleep overnight and during the day? If you have a schedule, describe the timing of naps/feeds/meals in a 24 hr period? Do you have a bedtime routine? If so, please explain what you do in the routine and the timing of this If formula fed, which formula is your baby currently using? Are there any known allergies for your baby? Asthma/skin allergies etc Has your child ever been diagnosed with any other medical conditions? Does your child currently take any medications? Or have they ever taken medications since birth? Has your baby ever had or currently experiencing colic/reflux/wind? Does your child snore, breathe with their mouth open or sweat during sleep? Does your child have nightmares? Describe your baby's temperament? (easy going, slow to warm up to, attached to one parent, adaptable, more emotional etc.) Thank you!
