Toddler Intake Form Parent 1 Name * First Name Last Name Parent 2 Name First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Child's Name First Name Last Name Child's Date of birth MM DD YYYY Child's current age Child's Current Height Child's current weight Child's Sex Currently, what are your greatest sleep challenges? When did you first notice this was happening? Please describe your child's sleep environment (bed type, lights, sounds, temperature, etc.) Please list any medical conditions and medications: When in bed, does your child? Watch TV Use a divide (iPad, Kindle, etc.) Read Listen to music None Other When sleeping, does your child? Snore Snore more than half of the time Snore loudly Have heavy or loud breathing Awaken with snoring/snorting sounds Have brief leg jerks or kicks Have restless sleep (tosses and turns, moves around, etc.) Get out of bed at night None of the above Has your child ever stopped breathing at night? If yes, please explain: Have you ever had to shake or move your child to get them to breathe again? If yes, please explain: Does your child sleep in a room alone? If no, please provide details: Is there a regular bedtime each night? If so, what time? On average, how long does it take for your child to fall asleep? Do you notice difficult behavior at bedtime? If yes, please explain: How often does your child wake up at night? Does your child wake up to use the bathroom during the night? What time does your child get up in the morning? Is your child difficult to awaken? Have you ever noticed any sleep walking episodes? Have you ever been awakened by the sound of your child screaming or crying at night? Has your child ever come to you because of bad dreams? When asleep, does your child bang his or her head on the pillow? Is there a time you need your child to be awake in the morning (for school, daycare, etc.)? Does your child regularly nap during the day? if so, when and for how long? Has your child ever simply stopped his or her activity and taken a nap where they were? Does your child drink caffeinated beverages? Has your child ever seemed to lose control of his or her arms (dropping objects) or legs (stumbling) involuntarily? Has your child ever become weak or unsteady when excited, surprised, or emotional? Does your child have tonsils? If no, when were they removed? Has a health professional ever said that your child has Attention Deficit Disorder (ADD) or Attention Deficit/Hyperactivity Disorder (ADHD)? How do you feel about crying? Are all caregivers on board with sleep training? How do you feel your child might respond to having you in the room during the sleep training experience? Have you spoken to your child's health care provider about their sleep? If yes, did they have any recommendations? What are your ultimate goals for the sleep training experience? Siblings names, ages, and bedtimes Is there anything else you think we should know? How did you hear about us? Family or Friend Social Media Pediatrician Other Did you have an ideal start date in mind? MM DD YYYY Thank you!