top of page
Home
Packages
About
Contact
Free call
Log In
Intake Form
Parent’s names
*
Child’s name
*
Email
*
Phone
*
Address
Child’s DOB
*
Day
Month
Month
Year
Child’s age
*
Child’s birth weight
*
Child’s current weight
*
Do you have any other children, people or pets living with you? *Please specify ages of other children and pet type:
Do you have any out-of-home commitments?
What are the main issues you are experiencing with your child's sleep?
What do you hope to achieve from this service?
How far along were you when your baby was delivered?
Did you experience any complications during your labour and delivery?
Did you have any vitamin deficiencies during your pregnancy? *Please specify and advise if supplements or infusions were required:
Did you require antibiotics during your labour and delivery? Or have you taken them while breastfeeding?
Yes
No
Does your child have any known medical conditions, allergies or intolerances? Please specify:
Has your child ever had:
Antibiotics
Gastroentiritis
Does your child currently experience or have they previously experienced any of the following?:
Colic
Reflux
Excessive vomiting
Poor weight gain or weight loss
Bowel issues (frequent diarrhoea, constipation, mucus or blood in stool, foul/acidic odour)
Wind and stomach aches/pains
Wheezing or other breathing problems/conditions
Difficulties introducing solids
Food textural aversions
Dummy refusal and/or dummy falls out during sleep
Excessive drooling
Inconsistent or poor sleep
Unsettled during awake periods
Speech challenges
Tooth decay
Constant congestion
Eczema or other rashes
Describe your child's motor skills and physical development (eg. rolling, crawling, pulling to stand, etc)
Does/did your child take a dummy?
Yes - has a dummy
Yes - but no longer uses one
No - didn't accepted a dummy
Dummy was never introduced
How does your child receive their milk intake? *if applicable
Breastfed
Formula bottle fed
Pumped breast milk, bottle fed
Mixed feeding (at the breast and pumped)
Combination feeding (breastmilk and formula)
Other
Please explain your child's milk feeding journey so far.
How many times does your child feed overnight and what is the duration/intake per feed? Do you want to adjust (increase or decrease) this?
Have you noticed your child presenting with (currently or previously):
Clicking sound when feeding
Chewing on nipple/teat
Fussiness at the breast
Difficulty latching while feeding (breast or bottle)
Unable to finish a whole feed when bottle fed
Falling asleep without a completed feed as a newborn
Uncoordinated suck or milk spilling from the mouth when feeding
Choking on milk/popping off the breast/bottle
Unintended early weaning from breastfeeding
Bloating and/or hardened stomach
Breast side preference
Frequent or prolonged feeding sessions
If breastfeeding, has mum experienced
Low milk supply
White tipped nipples
Mastitis
Vasospasm
Thrush
Blocked ducts
Blistered, cracked or bleeding nipples
Nipples that appear bruised, creased or pinched following a feed
Pain or discomfort during a feeding
Sleep deprivation (due to frequent/prolonged night feeding)
Anxiety and/or stress
Post-natal depression
How many times does your child breast/bottle feed throughout the day?
If your child has started solids, please specify how many meals/snacks they consume per day as well as examples of what they eat. Is their diet rich in iron and protein.
What time does your child wake up for the day and go to bed for the night? Is it the same everyday?
How does your child fall asleep for bedtime and naps? Do you assist them to sleep? Please specify:
Please specify how many naps your child has a day and how long they are:
Do you want to work towards establishing self-settling and/or resettling?
Yes
No
What is your ideal sleep schedule?
6:00am - 6:00pm
7:00am - 7:00pm
8:00am - 8:00pm
Other
Do you notice any of the following when your child is asleep? (If you are unsure, please observe your child for a few days)
Open mouth posture/mouth breathing
Snoring
Loud/audible breathing
Restless Sleep
Brief pauses in breathing
Constant congestion/waking up congested
Coughing/spluttering
Frequent night waking
Long periods of awake time overnight
Difficulty falling asleep/sleep resistance
Early morning waking
Frequent wakings after 3am
How often does your child wake up overnight and how long are these wakings? How does your child go back to sleep?
Where does your child sleep for the night? Is it the same for naps?
Describe your child's sleep environment
Dark room during the day
Bright room during the day
Bright room overnight
Dark room overnight
Night light used
Swaddled with a blanket
Wears a sleep bag/suit
Blanket
Sound machine/white noise
Does your child have any healthcare/allied health providers?
Is there anything else you would like to add?
Submit
bottom of page
