Sleep QuestionnairePINK Newborn Services Sleep Questionnaire Step 1 of 333%Parent 1, First and Last*Parent 2, First and LastAddress*Home PhoneParent 1, Mobile PhoneParent 2, Mobile PhoneWhat is your preferred contact number? Home Phone Parent 1, Mobile Phone Parent 2, Mobile PhonePreferred Email Address*What is your time zone?Baby's NameSexMaleFemaleBaby's Date of Birth Date Format: MM slash DD slash YYYY Baby's Birth WeightBaby's Last Known Weight and DateIs this your first baby?YesNoIs your baby breast-fed?YesNoDo you pump and offer expressed breast milk to your baby?YesNoDoes your baby drink formula?Yes, exclusivelyYes, as a supplement to breast milkNoHow many times in a 24 hour period does your baby drink a bottle?If your baby takes a bottle, what brand?If your baby drinks forumla, what brand? And what kind?About how many hours are there between feedings?Do you wake your baby to feed?Yes, we wake the baby at specific times to feedNo, the baby is fed on-demandDo you feed your baby to soothe or to sleep?YesNoDo you allow your baby to fall asleep shortly after a feeding?YesNoHas your baby been diagnosed with Reflux or infant GERD?YesNoIs your baby on any Rx medications? Please list.Does your baby frequently spit up during or after feedings?YesNoWhere does your baby usually sleep?What is the temperature in your baby's sleeping area?Does your baby ever sleep in bed with you?YesNoSometimesDoes your baby ever sleep in your arms or on your chest?YesNoSometimesDoes your baby ever sleep in a bouncy seat, swing, or other device?YesNoSometimesIf your baby sleeps in a crib or bassinet, is it in your room?YesNoDo you put your baby down after he/she falls alseep or while he/she is still awake?What does it take to get your baby to sleep? Please list (rocking, driving, feeding, etc).How long does it usually take to get your baby to sleep?How do you feel about your baby sleeping in a crib or in his or her own room?Does your baby need a pacifier to fall asleep?YesNoSometimesIf the previous answer was yes, does your baby wake up with the pacifier falls out?When your baby naps, how long does he/she usually sleep?Do you have a specific bedtime routine? If yes, please detial.When your baby wakes or fusses during a nap or nighttime, do you allow for some crying before you intervene?When your baby wakes during the night, do you pick him/her up right away or try to soothe in the crib?How many naps does your baby take in an average day and for how long?On most nights, how many times does your baby wake between 8pm and 6am?What time does your baby go to bed in the evening?Does your baby cry inconsolably? If yes, how ofen and for how long?Is your baby fussy during the day? Any particular time of day?Do you sometimes find it difficult to soothe your baby?What do you do to calm your fussy baby?Do you bathe your baby daily? What time of day?Does your baby use a pacifier? If so, how often?Do you or have you ever used loud white noise in Baby's room during sleeping times?What developmental milestones has your baby reached?Do you have daily play time, including tummy time?Do you have help (nanny, housekeeper, family, friends)?Have there been any medical issues for Mom or Baby since the birth?Do you ever feel angry or resentful toward your baby?What are your biggest concerns regarding your baby?What would you most like to achieve while working with PINK?*Are you comfortable with a moderate, age appropriate amount of crying?How long are you willing to allow your baby to fuss or cry before intervening?Are youType A, structured person who likes predictibilityType B, relaxed and spontaneous personNeither or somewhere in betweenPlease detail a 24-hour period, including feeding times and amounts, naps/sleep times, diapers, play time, etc.*
