Protected: Newborn HistoryPlease complete and submit this history for your newborn. Parent #1 * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent #2 First Name Last Name Phone (###) ### #### Email Baby's name * First Name Last Name Baby's date of birth * MM DD YYYY Was your baby born full term? * Yes No Other If no, how many weeks? Were there any problems during pregnancy? * Yes No If there were problems during your pregnancy, please describe. Delivery/Labor * Vaginal C-section VBAC Is your baby * Breastfed Formula fed Both Any medical problems for your baby at birth? If yes, please describe. * Is your baby currently having any medical problems or discomforts? * Reflux Gassiness Eczema Other If your baby is having any medical problems, please describe any treatment he/she is receiving. How much does your child weigh and when was the last weight check? * What percentile for weight is your child in? * What was your baby's weight at birth? * Are you able to sleep at night when your child is sleeping? * Yes No Questions for your child's mother Do you currently have any support at home? * No Yes If yes, who is there to provide additional support? How is your appetite? * Are you having any troubling or scary thoughts? * Yes No Does your baby sleep swaddled? * No Yes If yes, please describe what you swaddle your baby in Does your child use a pacifier? * Yes No Where does your baby sleep at night? (for example, in his/her crib, in a bassinet in parents' room, in a Rock n Play, swing, being held, etc.) * Have you noticed an increase in your baby's night wakings? If yes, what was happening before and what is happening now? * Where is your baby currently sleeping for naps? * Do you find that your baby has become more distracted during feedings? * If your baby's sleep has started to take on any sort of a schedule, please describe. If not, please give an approximation of what sleep looks like on average (knowing that there are likely to be many exceptions at this age). * After night feedings, how does your baby do with going back to sleep? For example, do you feed him/her and are able to put your baby right back down and he/she is back to sleep or does it take a lot of work for him/her to go back to sleep after feedings? * Have you noticed any self soothing behaviors? If yes, what have you noticed? * Has your baby started rolling over? If yes, when? Is your baby rolling just one direction (only back to front or front to back) or both ways? * What are your concerns regarding your newborn's sleep? * Thank you!
