Infant Intake Form
The Slumber Studio, LLC
Baby's name
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First Name
Last Name
Age of baby in months:
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Baby's date of birth:
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Year
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Month
Day
Date
Parent's name:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Canada
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Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Democratic Republic of the Congo
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Djibouti
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Dominican Republic
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El Salvador
Equatorial Guinea
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Ethiopia
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Faroe Islands
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The Gambia
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Iran
Iraq
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Jamaica
Japan
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Kenya
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Laos
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Lebanon
Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
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Area Code
Phone Number
E-mail
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How did you hear about The Slumber Studio?
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Please Select
Instagram
Facebook
Internet search
Other (Please specify...)
Other
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Date of last pediatrician visit:
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Year
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Month
Day
Date
If not full term, how early?
Baby's weight:
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Describe the sleep issues your baby is having:
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At night, does baby sleep in your room or their own room?
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My room
Their own room
Describe your baby's room environment (temperature, blackout curtains, use of white noise, etc):
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Please describe your bedtime routine in detail:
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Describe the environments your baby sleeps in during the day and at night (crib, pack-n-play, stroller, carseat, etc):
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In what position does your baby sleep the majority of the time?
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On back
On side
On belly
Average number of wakings per night?
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How do you typically handle night wakings? (feed to sleep, rock to sleep, pacify to sleep, etc.)
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How many night feedings do you give your baby? How many night feedings do you want to keep, if any?
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How is baby put to sleep? (rocking, feeding, etc)
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What is baby put to sleep in?
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Swaddle
Sleep sack
Magic Merlin
Just pajamas
Does your baby use a pacifier?
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How much sunlight is your baby exposed to each day?
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How much screen time is your baby exposed to per day:
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Is your baby breastfeeding, infant formula feeding or both?
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List your baby's typical feeding times:
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Has your baby developed predictable eating and sleeping patterns?
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Does your baby have any known allergies, asthma, reflux, medical issues or conditions? Is your baby on any medications?
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Do you believe your baby has colic?
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Does your baby snore, sweat or breathe with their mouth open during sleep?
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Does your baby ever wake up with nightmares?
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Describe your baby's temperament - easy going, laid back, stubborn, independent, clingy, difficult, mixed, etc:
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How much activity/floor time does your baby get each day?
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How does your baby respond to new sensory experiences?
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What time does your baby typically go to bed at night?
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What time does your baby typically wake up in the morning?
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Is your baby in daycare or do they have regularly scheduled child care with someone that is not a parent such as a babysitter, nanny, family member, friend, etc?
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If your baby is in some form of childcare, are they on a set sleep schedule that is different than their typical sleep schedule at home? If so, please describe:
Please describe your primary goal(s) for us to work on:
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Is there anything else I should be aware of or give consideration to when making a sleep plan for your baby?
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Submit
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