Please complete this form to the best of your ability. Child's name * First Name Last Name Child's date of birth * Child's address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent 1 name (first and last) * Preferred name to be called if different from above Parent occupation * Parent 1 phone number * (###) ### #### Parent 1 email * Parent 2 name (first and last, if single parent, please enter NA) * Preferred name to be called if different from above Parent occupation * Enter NA if single parent Parent 2 phone number (###) ### #### Parent 2 email address How did you hear about Sleep Tight Consultants or who referred you? * Siblings name(s) and age(s) * Enter NA if your child does not have siblings Does your child have any formal diagnoses? * Yes No If your child does have any formal diagnoses, please describe. If no, enter NA. * Does your child take any medications? * Yes No If yes, what medications? If no, enter NA. * Does your child do any of the following: * Snore Mouth breathe Sweat in their sleep None of the above Are there any school concerns? * Yes No Would you describe your child as an anxious child? * Yes No If you would consider your child an anxious child, please describe what this looks like? Where do you see the anxiety happen? Is school describing instances where your child seems anxious? Do other people comment on this? * If your child is not anxious, enter NA Would you consider your child "restless?" This can mean in their sleep and also during the day in general. * Yes No If you answered that you would describe your child as "restless," please elaborate. * If you answered No, enter NA If there are school concerns. If there are no school concerns, please enter NA. * What, if anything, have you done to try to change your child's sleep behavior in the past? If you have done anything, when was it? What did this look like? Was it effective, even briefly? What led to you child's sleep changing to what it looks like now? * If you haven't ever attempted to change your child's sleep, enter NA Please describe your child's sleep concerns. What are the challenges? * How long have these sleep challenges been present? * Does your child participate in any evening activities such as sports or lessons? If so, what is the timing of these activities? * If there are no such activities, enter NA. What time does your child go to bed? Is this time the same very night? If no, please describe why not. * How long does it take for your child to fall asleep at night? * What rituals or routines does your child do to get ready for bed? * What does your child do one hour prior to falling asleep? * Does your child wake in middle of night? How long is your child awake for? Describe how your child goes back to sleep. * Where does your child sleep? Own room? Share with others? Bed share? * Describe the area your child sleeps in – dark, lights shine in, temperature of room at night, noises from outside of room * What items of support does your child depend on for sleeping? Parent presence? toys, stuffed animals, night lights, sound machines, door open/closed, soothing items such as special blanket, weighted blanket, essential oils, etc * Have there been any major changes in your family recently or in the past that may have spiked your child’s sleep issues? (moving homes, change of teacher or school, family separation, death in family or of a pet....) * Describe what things have you tried with your child to help them with their sleeping? (ie: sleep with them, stay with them till they fall asleep, wake them in middle of the night to go to the bathroom....) * As the parent(s) of your child, how would you describe your own sleep habits now as an adult and when you were a child? * Is there anything else I should know in order to best help your family? * Thank you! 6-10 year old History form
