Infant Intake Form

Baby's name*

First NameLast Name

Age of baby in months:*

Baby's date of birth:*

Date

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:*

Date

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?*