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Pediatric Sleep Evaluation Copy, Draft (new form)

Pediatric Sleep Evaluation Copy, Draft (new form)

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Customize Plan
Sleep Environment
Sleep Goals
Parent Profile

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Keep going customizing your child's REST Plan. You can also:

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Newborns
Infants
Toddlers
Toddlers/preschoolers
School-aged children
Let's get to know more about your child's sleep!
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Customize Your Child's Sleep Plan
Sleep Environment
Sleep goals
Sleep goals
Sleep goals
Parent profile
Parent profile

Get Started

How old is your child?*

Newborn (0-3 months)

Infant (4-11 months)

Young toddler (12-23 months)

Toddler (2-4 years)

School age (5-9 years)

Newborns

We classify newborns between the ages of 0-3 months. Learn the fundamentals of newborn sleep while developing realistic sleep goals for your newborn. Your REST plan will not only focus on your newborn but also help you as a parent get the rest needed.

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Infants

We classify infants as babies between the ages of 4-11 months. Your little infant's sleep habits are developing at this critical stage. Your REST Plan will address shaping these habits and transitions as your infant starts to sleep independently and routinely.

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Toddlers

We classify toddlers between the ages of 12-23 months. Children in this age group change drastically when it comes to sleep. Anxieties and fears may come into play, and habits can be harder to break. Your REST Plan addresses this development stage with the empathy and understanding required to create better sleep.

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Toddlers/preschoolers

We classify toddlers/preschoolers between the ages of 2-4 years. Like younger toddlers, older toddlers require additional understanding and sleep considerations. Your REST Plan addresses anxieties, fears, and sleep environment dependencies that older toddlers may reinforce at this age group.

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School-aged children

We classify school-aged children between the ages of 5-9 years old. School-age children usually have anxiety, attachment or emotional development needs associated with their sleep difficulties. Your REST Plan will flesh out these sleep issues and provide routine, guidance and continued support for families to get their sleep back.

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Let's get to know more about your child's sleep!

We personalize your experience to determine if you can reach your sleep goals sooner

Your full name

Child's name

Your email

Restfully does not share your information and provides you a copy of the questionnaire answers. By submitting your email address, you may also receive email offers from us on Restfully products and services. Please see our privacy policy and terms of service for additional information for details.

Customize Your Child's Sleep Plan

What is your child's gender?*

Male

Female

What is your child's birthdate?*

Select Date ×

Was your child born less than 38 weeks from the expected due date?*

Yes

No

Restfully uses data from child developmental progression and successful client outcomes to create your custom plan & coach appropriate sleep habits for your child. The results of this evaluation are not guaranteed and clients who use Restfully can expect to see improvement weekly.

Customize Your Child's Sleep Plan

What was your child’s due date?*

Select Date ×

Customize Your Child's Sleep Plan

What is your infant currently eating?*

You may select more than one

Exclusively Breastfed (Nursed or Bottle-fed Breast Milk)

Exclusively Formula

Combination of formula and breastmilk

Solids

How many ounces per bottle is your child currently receiving? *

0 per bottle

How often are feedings in a 24 hour period?*

0 per 24 hour period

How many breast feeding sessions in a 24 hour period?*

0 per 24 hour period

Customize Your Child's Sleep Plan

How often does your toddler nap during the day time?*

One nap

Two naps

Naps infrequently

Is your toddler currently nursing, bottle feeding, or using a toddler cup?*

Breastfeeding

Bottle feeding (breast milk or formula)

Toddler cup

Customize Your Child's Sleep Plan

How often does your child nap during the day time?*

One nap

Two naps

Naps infrequently

Customize Your Child's Sleep Plan

Where does your child sleep at night?*

Own room (alone)

Roomsharing with sibling

Parent's bed (with parent)

Child's bed (with parent)

Does your child sleep in a crib or a bed at night?*

Crib

Bed

Customize Your Child's Sleep Plan

What room does your infant sleep in?*

Parent's room

Separate room

What does your infant sleep in?*

Select all that apply

Parent's bed

Own crib / bassinet

Dock a Tot / Snuggle Me Organic / Boppy / Lounger

SNOO

Swing

Customize Your Child's Sleep Plan

What time does your child typically wake up in the morning?*

Before 5am

Between 5-6am

Between 6-7am

Between 7-8am

After 8am

What time does your child typically go to bed at night?*

Before 5pm

Between 5-6pm

Between 6-7pm

Between 7-8pm

Between 8-9pm

After 9pm

Customize Your Child's Sleep Plan

How many naps does your infant take during the daytime?*

1

2

3

4+

My baby can't seem to nap

How long does your infant typically nap during the daytime? *

(use the first two naps as reference)

0-30 minutes

30-60 minutes

60-90 minutes

none

3+ hours

Customize Your Child's Sleep Plan

Has your child ever experienced any of the following? *

You may select more than one

Acid reflux

Allergies (skin)

Allergies (food)

Ear infections / ear tubes

Weight gain issues

Other

None of these

Customize Your Child's Sleep Plan

How does your child currently fall asleep for nights and naps?*

You may select more than one

Feeding

Rocking/bouncing/holding

Pacifier

Equipment (car seat, stroller, swing, bouncer, etc)

Babywearing

Completely on their own

Viewing devices (tablets, smart phones)

Independently (put right down)

Other

Customize Your Child's Sleep Plan

Is your child currently working with an occupational or physical therapist to address any of the following?*

Gross motor

Fine motor

Language

Other

None of these

Does your toddler have a caregiver during the day time (outside of school)?*

Parent/guardian

Daycare

Nanny

Babysitter

Family member (non parent)

Does your child express any fears or anxieties?*

Yes

No

Have there been any recent changes in your child’s life?*

New classroom

New teacher or caregiver

Transition from crib to bed

New sibling

New home

None of these

Sleep Environment

Does the room where your child sleeps have blackout type shades?*

Yes

No

Does your child use a night light?*

Yes

No

Do you use a sound machine?*

Music / Waves / Rain / White Noise

Yes

No

Does your child wear a sleep sack or swaddle?*

Yes

No

Sleep goals

Please rate your child’s sleep issues using the scale below*

(1 - Never, 5 - Always)

Trouble falling asleep at bedtime

1

5

Waking multiple times throughout the night

1

5

Waking up too early in the morning

1

5

Difficult to wake in the morning

1

5

Taking short naps

1

5

Groggy/tired throughout the day

1

5

Sleep goals

What goals would you like to accomplish with your pediatric sleep support? *

You may select more than one

Sleep through the night / fewer night walking

Longer, more predictable naps

Easier bedtime (takes forever to sleep)

Transition from co-sleeping into own crib/bed

A more predictable schedule

Less sleep disruption during traveling or vacation

Sleep goals

Have you tried Sleep Coaching in the past?*

Yes

No

Please feel free to share anything else that you think is important for us to know about your child or family situation.

Write Here

Parent profile

We want to know how you are feeling too! *

Describe how you feel at this moment (1 - Not at all, 5 - Extremely):

Tense

1

5

Angry

1

5

Worn out

1

5

Unhappy

1

5

Confused

1

5

Lively

1

5

Fatigued

1

5

Sad

1

5

Active

1

5

On edge

1

5

Blue

1

5

Restless

1

5

Uneasy

1

5

Energetic

1

5

Parent profile

Please rate the areas of your life that have been most impacted by your child's sleep issues?*

(1 - Not impacted, 5 - Extremely impacted)

Sleep deprivation for entire household

1

5

Change in mood for parents

1

5

Change in mood for child

1

5

Relationship issues for parents

1

5

Feelings of anxiousness around sleep

1

5

Choose sleep coach support

Choose your sleep coach package*

Each plan includes 24/7, on-demand REST coach support, customized sleep plan for your child, sleep tracker & newborn tutorials

7 day sleep coaching

14 day sleep coaching

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