Infant Intake Form

Infant Intake Form
The Slumber Studio, LLC
Baby's name
First NameLast Name
Age of baby in months:
Baby's date of birth:
YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Parent's name:
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number
Area CodePhone Number
E-mail
How did you hear about The Slumber Studio?
Other
Date of last pediatrician visit:
YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
If not full term, how early?
Baby's weight:
Describe the sleep issues your baby is having:
At night, does baby sleep in your room or their own room?
Describe your baby's room environment (temperature, blackout curtains, use of white noise, etc):
Please describe your bedtime routine in detail:
Describe the environments your baby sleeps in during the day and at night (crib, pack-n-play, stroller, carseat, etc):
In what position does your baby sleep the majority of the time?
Average number of wakings per night?
How do you typically handle night wakings? (feed to sleep, rock to sleep, pacify to sleep, etc.)
How many night feedings do you give your baby? How many night feedings do you want to keep, if any?
How is baby put to sleep? (rocking, feeding, etc)
What is baby put to sleep in?
Does your baby use a pacifier?
How much sunlight is your baby exposed to each day?
How much screen time is your baby exposed to per day:
Is your baby breastfeeding, infant formula feeding or both?
List your baby's typical feeding times:
Has your baby developed predictable eating and sleeping patterns?
Does your baby have any known allergies, asthma, reflux, medical issues or conditions? Is your baby on any medications?
Do you believe your baby has colic?
Does your baby snore, sweat or breathe with their mouth open during sleep?
Does your baby ever wake up with nightmares?
Describe your baby's temperament - easy going, laid back, stubborn, independent, clingy, difficult, mixed, etc:
How much activity/floor time does your baby get each day?
How does your baby respond to new sensory experiences?
What time does your baby typically go to bed at night?
What time does your baby typically wake up in the morning?
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?
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:
Is there anything else I should be aware of or give consideration to when making a sleep plan for your baby?
Should be Empty: