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Name of Child*

Name of Person Filling out Questionnaire*

Contact Telephone Number*


City *


Postal Code*

Email Address*

Is your child wearing underwear?

How long does your child stay dry?

Does your child ever wake up dry?

Has your child ever voided on the potty?

If so, urine or feces?

Does your child experience constipation?

Does your child have frequent soft stool or diarrhea?

Does your child dress him/herself?

Does your child respond to his/her name?

Does your child follow simple directions as part of a familiar routine?

Does your child enjoy a variety of items/activities?

Please list a variety of items/activities your child enjoys

Will your child comply/work for a specified reward? For example: when told "First put your cup in the sink and then you may have the cookie, your child will put the cup in the sink

Does your child demonstrate preferences?

Does your child have a method of communicating wants/needs?

If so, what is your child's means of communication?

Please list any medical problems your child has:

Please list any medications your child is taking:

Please list types of therapy your child is receiving:

Please tell us any special information you want to share that you feel will help us potty train him/her:

Has your physician approved of your child receiving potty training?

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