Please answer all questions fully and with as much detail as possible.

Parent's Name

First Name

Last Name

Child's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Date of Birth

Date of last doctor's visit

Please list any current medical conditions

Please list any previous medical conditions

Please list all current medications

Does your child have a history of constipation?

How often does your child have a bowel movement?

How often does your child urinate?

Who are the caregivers in the home?

Describe your child's typical day (e.g. naps, nanny, daycare, school, bedtime, wake up, etc)

If you've tried toilet training before, please list method used and when:

What is your reaction like when your child has an accident?

Is your child in diapers, pull-ups, or underwear?

Do you have any toilet training materials (e.g. mini potty, seat on toilet, books, etc.)?

How long has this been an issue for your child/family?

If your child is old enough, describe how he/she talks about using the potty (e.g. fearful, excited, neutral, etc.)

Describe any major incidents surrounding the toilet in the past:

What is typically happening right before a bowel movement or urination?

Is your child on a predictable schedule for bowel movements? If so, what is it?

What are your child's favorite treats (e.g. stickers, trip to Disneyland, oreo cookies, stamps, etc.)

Describe your child's nutrition (e.g. picky eater, refuses to eat veggies, etc.)

Describe your child's overall temperament (e.g. shy, outgoing, frustrated easily, etc.)

Please list any additional information regarding your child's behavior in general, or anything else you'd like me to know:

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