Child Toilet Training

Name of the Child *

Name of the Parent & Place *

Name of the Doctor Referring & Contact Number

Contact Number of Parent *

Email Address

Date of Birth of Child *

My child *Aware of his / her own need to eliminate urine and stoolInitiates to go to toilet without being reminded / prepared by parentsSpends whole night without wettingGoes to toilet by controlling faeces and urine in the day timeCompletely transferred from using nappy

My child has *ADHDAUTISMDOWN's SYNDROMENORMAL DEVELOPMENTOTHER PROBLEMS

In case other problems, please specify

Education Level of mother & Is Mother employed / house wife *

At what age of the child you started toilet training & total duration till now *

How often did you take your child to the toilet during toilet training? *

Has your child’s toilet training been interrupted for any reason? *

1. My child may imitate other people’s behaviour or actions *YesNo

2. My child can stand or walk unaided *YesNo

3. My child has enough language skills to explain that he/she needs to go to the toilet *YesNo

4. My child can say “no” as a sign of independence *YesNo

5. My child can understand and follow up simple commands *YesNo

6. My child can pick up things on his/her own and put them back where they belong *YesNo

7. My child has a tendency to and interested in using the toilet *YesNo

8. My child gives a favourite object to a favourite person *YesNo

9. My child can dress or undress on his/her own *YesNo

10. My child feels uncomfortable after wetting/pooping him/herself or his/her nappy *YesNo

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