Child's Sleeping History and Development

Sleeping Assessment

Child's Sleeping History and Development

This questionnaire addresses your child and family from a historical as well as a present-day perspective. It will help you remember significant events and allow me to get a feeling for your child and family.

Child's Full Name

Date of Birth

Month

Day

Year

Age

School or childcare, if any

Address

Phone Number

Parents and Guardians

First Parent

Parent's Name

Age

Pronouns

Occupation

Hours of Work

Language(s) spoken by this parent, especially to the child

What do the child and parent like to do together?

Second Parent

Parent's Name

Age

Pronouns

Occupation

Hours of Work

Language(s) spoken by this parent, especially to the child

What do the child and parent like to do together?

_______________

Does one of these parents or guardians reside at a different address from the child? If so, please describe the arrangements for custody and shared parenting.

Other Family and Caregivers

Siblings (including step-siblings and foster children present in the home):

Please include their name, age, gender, and any concerns you may have about the child.

Please list any other people that live or have lived in your home, care for the child, or have a significant influence on your family:

Please include their name, relationship to the child, and why this person is or was important to you or your child.

Which of the above parents, guardians, and caregivers contributed to this form and the other assessment materials?

Were there any serious family events or crises since your child's birth? Please describe them.

Your Child's Sleep

Please describe any difficulties your child experienced with sleep up until this point.

Sleep as a newborn:

Sleep as a young infant (pre-crawling):

Sleep as a crawling infant:

Sleep as an infant who could toddle/walk:

And during the years following (1-2 years old, 2-3 years old, preschool, elementary school, etc):

Who helps your child sleep? Describe the role of each person.

Do all parents and caregivers share a similar point of view with regards to current and past sleep issues, for example, whether there is a problem at all, what the problem is, what it is caused by, what to do about it?

Your Child's Development

What about your child's development, personality, or behavior do you enjoy the most?

What about your child's development, personality, or behavior do you find the most challenging?

Do you have other concerns about your child's development (physically, emotionally, mentally)? If so, please describe those concerns here, including how long you have felt concerned.

Child's Medical Information

Were there medical difficulties during the pregnancy? If so, please describe them.

Were there medical difficulties during the birth or shortly after? If so, please describe.

Were there medical difficulties with the parents or other family, for example, significant illnesses or post-partum depression or anxiety?

When was your child last examined by a physician?

Were any problems with your child's health or development reported during this visit?

If you discussed concerns about your child's sleep with the physician, please report your physician's recommendations here:

_______________

Please share any other comments you would like to make about your child or your family:

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Sleeping Assessment