Child Toilet Training Readiness

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

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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