In order for us to follow the progress of your wee one, please answer the questions below in the spaces provided for a two-day period and then send the completed form to your consultant.
Your progress will save automatically! Feel free to navigate away from this form and return to it ON THE SAME DEVICE & WITH THE SAME BROWSER, and the data you entered will be preserved!
Parent's Name
Phone Number
Child's Name
Date
DAY ONE SCHEDULE
1. What time did your child wake to start the day?
2. What time did the first nap occur?
3. How did your child fall asleep for this nap? Please describe.
4. What time did your child wake from this nap?
5. What did you do when your child woke up? Please include feeding times, details, activities etc.
6. If applicable, what time did the second nap occur?
7. How did your child fall asleep for this nap? Please describe.
8. What time did your child wake from this nap?
9. What did you do when your child woke up? Please include feeding times, details, activities etc.
10. If applicable, what time did the third nap occur?
11. How did your child fall asleep for this nap? Please describe.
12. What time did your child wake from this nap?
13. What did you do when your child woke up? Please include feeding times, details, activities etc.
14. If applicable, what time did the fourth nap occur?
15. How did your child fall asleep for this nap? Please describe.
16. What time did your child wake from this nap?
17. What did you do when your child woke up? Please include feeding times, details, activities etc.
18. What time did the bedtime ritual start?
19. What did you do for the pre-bedtime routine? Please list in order. (For example: bath, brush teeth, sing songs, read stories, play a game etc.)
20. What time was your child in bed for the night?
21. What time did (s)he fall asleep?
22. How did (s)he fall asleep?
23. What happened during the night? Please describe how many wakes, how you responded etc.
DAY TWO SCHEDULE