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Toileting Questionaire

Each child can be different when it comes to potty training. In order for us to obtain more insight into your where your child is at this time, please complete the questionnaire below being as descriptive as possible. An asterisk * denotes a required field.

Click here for a printable version.

Your Name*:

Your Phone Number:

Your Email Address*:

Your Child's Name:

1) Is your child able to have prolonged periods of dryness between changings? (Physical)

2) Does your child give you a physical or verbal sign that they are about to urinate or have a bowel movement? For example, does your child cross their legs? Hold themselves in some way? Go off to a corner of the room? (Cognitive, Physical)

3) Is your child capable of pulling down their own pants for the most part? (Physical)

4) Does your child take an interest whenever others use the bathroom? Do they model what you may do in the bathroom? (Emotional)

5) What does your child do when they have a dirty diaper? Do they keep playing? Do they show a physical sign or verbally tell you that they need to be changed? (Physical, Emotional)

6) Does your child notice that adults wear underwear? Do they tell you that they wear underwear too (even if it is a diaper/pullup)? (Emotional)

7) Is your child capable of following one or two step instructions? Does he/she usually do so happily? (Cognitive)

8) Does your child display a sense of accomplishment at completing tasks or in creating something? (Emotional)

9) Does your child sit on the toilet, even if he/she is just placed there? (Emotional)

10) Will your family be undergoing any lifestyle changes in the time that your child will be potty training? (Moving, Baby, Schedule Change)