CLIENT INTAKE – OVER 12 MONTHS Order Number First Name * Last Name * Email Address * Child's Name * Child's Age * Child's Birthdate * Was your child born at term/premature/late? Please give details What is your child's current weight? * Does your child snore? If so please give details * Does your child have any medical problems or allergies? * How would you describe your child's temperament? (e.g fussy a lot, generally happy, clingy, easy going, adaptable, up and down) * Do you believe your child is reaching age appropriate milestones? (your child health book should have descriptions of these if you are unsure) * Please describe what your child sleeps in (sleeping bag, swaddle, doona, blankets, PJ's) * Does your child use a comforter or dummy? Please give details. * Describe your child's sleep environment (e.g the room is brightly lit/darkish, mobile over the cot, lots of toys/minimal toys, nightlight, air conditioned/heated to ...degrees) * Where does your child sleep for naps and night sleep (e.g. naps in lounge room in pram, naps in own room in cot, my room and bed at night/own room in cot then my bed later) * How many naps does your child usually have? Please give details of times and duration. * How do you settle your child for a nap? * What time does your child usually go to bed at night and how do you settle your child at bedtime? * How do you settle your child back to sleep if he/she wakes at night and how often do they usually wake overnight? * What does your baby drink? * Only Breast milk Only Formula Breast milk and Formula Other Please give details of milk feeds: approximate times over 24 hours, volume etc If breast fed, how long at each breast? * Please list approximate times over 24 hours of any solid feeds (meals and snacks). Give details of homemade meals, brands of store bought foods and approx. quantities of foods. * Do you work outside the home? If yes, which days and for how long? Who looks after your child? * Do you have other children. If yes, how many and how old are they? * Do you have any commitments outside the home (apart from work) like school/gym classes/shopping? If yes, please list times you have to leave the house and when you get back. * Do you prefer a strict schedule during the day with predictable wake up times, nap times and bedtimes or do you prefer a more exible 'go with the flow' day and bedtime? * How long can you let your child cry before you feel you have to pick him/her up? * I try and pick him/her up straight away Up to 5 minutes Up to 10 minutes Up to 15 minutes Other Have you tried sleep training before? If so, what did you try and what was the outcome? * Please describe in detail what exactly the sleep problem is that you are having and what you'd like to work on. *