Client History Form Client History Form Child Evaluation Parent Name First Last AgeOccupationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country List the names and birthdates of other members of household. Please place an asterisk (*) next to the name of the child you are seeking help for:NameBirthdateAge Phone (best number for morning follow ups)*Email Who referred you? How did you hear about me?Child's Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Was this a planned pregnancy? Yes No Were there any problems during the pregnancy? If yes, please describeDelivery/Labor Vaginal C-Section VBAC Were there any complications during delivery? If yes, please describeWas your child born full term? If no, at how many weeks?Any medical problems for newborn at birth? If yes, please describeAre you able to sleep at night when your child is sleeping?How is your appetite?Are you having any troubling/scary thoughts?What is your pediatrician's name?What is the name of your pediatrician's practice?Pediatrician's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Pediatrician's phone numberHas your pediatrician ruled out any medical problems that may be causing or contributing to your child's sleep problems? If no, please describeWould your pediatrician state that your child "should" be able to sleep through the night given their age, weight and medical health? If no, please describeAt approximately what age did your child reach the following milestones. Rolling over:Sitting UpScooting/Army CrawlCrawlingStandingWalking1st wordsIs your child formula fed, breast fed, both or neither/weaned?Has your baby started solids? If so, at what age?What is your child's weight and what percentile are they in?Check the box if your child: Sucks thumb/fingers Uses a pacifier Has a security object (blanket, stuffed animal, etc.) Has there been any past or current medical or developmental problems? If yes, please describeDoes your child wet the bed (if potty trained) during the night? Yes No If yes, how often and is there a pattern to the bedwetting?Does your child sleepwalk? If yes, how often and at what time?Does your child snore? Yes No Does your child mouth breath? Yes No Does your child fall out of bed? Yes No Is your child a restless sleeper? Yes No Does your child sweat while sleeping? Yes No Does (or did) your child have reflux problems or colic? IF so, how long did it last? When was it resolved and what helped?Does your child have any of the following: Allergies Frequent ear infections Asthma Frequent or constant stuffy nose Does your child have nightmares? If yes, how often and at what time during the night?Please outline your current typical 24-hour schedule with your child in detail from waking up and through the night. (Please include feeding amounts, nurse vs. bottle if you do both and times fed. Also include what you do to try to help your child sleep)Are your child's sleeping disturbances new or ongoing since infancy?What techniques have you tried up to this point to address your child's sleep problem?Does your child in a crib or bed? Crib Bed Where is your child sleeping now?If your child sleeps in your bed, does your spouse see this as a problem or something they want to change?Does the sleeping location change during the evening/night? For example, does he/she fall asleep in your bed and then have to be moved in his/her own bed? Or does he/she fall asleep in his/her own bed and then come into your bed during the night?Does he/she share a bedroom with a parent, brother, sister or someone else? Yes No Does he/she share a bedroom with a parent, brother, sister or someone else? Yes No Does he/she stay in his crib/bed without trying to get out? Yes No Does he/she get out of bed during the night? If yes, where does he/she go?How do you get him/her to sleep? Please describe the routineHow long before bedtime do you start this routine?Is there a fixed bedtime? If so, what time is it?If you have other children, do they go to bed at the same time? Yes No Does your child seem sleepy during the day but doesn't take a nap? Yes No Is your child afraid of the dark? Yes No Is either parent afraid of the dark? Yes No Do you leave a night light on for your child, or the bedroom door open? Yes No Does your child head bang or rock his/her body? Yes No Is your child distressed when he/she is left alone in his/her crib/bed? If yes, what do you do?Do you stay with your child while he/she goes to sleep, or do you leave him/her to fall asleep on his own? If you stay, how long do you stay for?How long does it take your child to go to sleep?Is there a pattern to your child's night awakenings? For example, does he/she wake at approximately the same time?How would you describe your child's temperament?How does your child handle time by him/herself?Are there rituals or certain things that your child does to self-soothe?Do your other children currently have (or previously have problems with sleep? If yes, what did you do to address it?)Are both parents in support and willing to participate in helping your child learn to sleep through the night? Yes No What is the ultimate outcome you and your spouse would like to see with regard to your child's sleep habits? Please be specific. For example, what would you like your child's sleep schedule and sleep habits to look like at the conclusion of treatment?