Potty Training History Form

POTTY TRAINING HISTORY FORM

Please also complete this in one sitting and on a computer rather than a mobile device.
Parent #1*

First NameLast Name
E-mail*
Don't worry, we're not going to spam you.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Parent #2

First NameLast Name
Parent #2 E-mail
Don't worry, we're not going to spam you.
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age (in months)*
Any Medical History (Current or Resolved?)*
Please outline your child's daily schedule including morning wake time, mealtimes, nap time and length and bedtime. *
Are there are any siblings?*

YesNo
What are their names and ages?
Have you started potty training already?*

YesNo
How is the process going so far?
Is your child still wearing diapers/pull-ups for sleep?

YesNo
Have you started and stopped potty training previously?*

YesNo
When did you stop and why?
Please describe your child's general personality and temperament. *
Does your child sleep in a crib or a bed?*

CribBed
When do you intend to move them to a bed?
Does your child know how to pull up and push down their pants by themselves?*

YesNo
Do you have any concerns or struggles surrounding your child's sleep habits, routines, or patterns?*
Is there anyone else involved in your child's daily care such as a nanny, Grandma, or daycare/school?*

NannyGrandmaDaycare/SchoolN/AOther
How often do they care for your child?
What is the school's approach and expectation with respect to potty training?
Are there any time constraints on when your child needs to be potty trained?*
Do you have or plan to offer a potty in addition to the toilet?*

YesNo
Does your child drink well throughout the day?*
Is having a drink part of the bedtime routine?*

YesNo
If not, when are their last fluids consumed?
Does your child tell you when they need to go or after they have gone?*
Do they tend to seek privacy to go? If so, where?*
Does your child have a history of constipation or diarrhea? *
Please describe the concerns you have surrounding potty training.*
What do you hope to accomplish or address by working together?*
How did you hear about Confident Parenting? If you were referred by a friend, colleague or family member, please provide their name so we can gift them a complimentary support call as a thank you!*
Should be Empty:

POTTY TRAINING HISTORY FORM