Toileting Questionnaire

Client Name

Date of Birth

Name of Person completing this Form

At what stage of toileting learning are you. *

In nappies and wanting to start toilet learning. Complete section AInconsistent toileting behaviours . Complete section BWorking on toileting independence. Complete questions which apply to you in Section B.

Section A

When would you like to start toilet learning?

Are you planning on using a potty or the home's toilet?

Is your toilet in a bathroom or independent from the bathroom? Please describe the bathroom or toilet which will be used.

Upon waking, is their nappy wet or dry?

WetDryVariable

Upon waking, how long until they have a wet nappy?

What signs does your child show before weeing?

What signs does your child show during weeing?

Does your child show any signs of recognizing that they have done a wee?

How often does you child poo?

Using the below image, what consistency is your child's poo?

Does your child become constipated and do you use any medications for constipation?

What is your nappy change procedure? And how involved is your child?

Does your child have a history of urinary tract infections? If so please explain.

Section B

What is your current focus in toilet learning?

How long have you been working on toileting?

Do you have a particular problem or issue?

Is your child using the toilet or potty? And are they happy to sit on the toilet or potty, please explain.

Does your child wear underwear or nappies? Please describe current use.

Does your child wet or soil their underwear and how often. If they do wet or soil their underwear would it be a full wee or poo or partial?

What signs does your child show of knowing they are having an accident?

Does your child sense the accident?

Does your child have accidents during particular activities, times of day or in certain environments?

Does your child take themselves to the toilet or do they need prompting. Please describe support provided.

Will your child use the toilet for wee and poo? Please explain

Will your child wipe themselves. Please explain.

What steps of the toileting process will your child complete independently. For example, lifting lid, wiping, flushing etc..

Does your child attend the bathroom alone? Or with you?

Does your child have a sudden urge to go to the toilet and how long can they wait from sensing need to having to toilet?

Is your child dry overnight?

Does your child strain to go to the toilet?

Using the image below, What consistency is your child's poo?

How often does your child poo?

What signs of toileting need are present before a wee and poo

What strategies have you used and are currently using for example taking your child to the toilet every hour etc.?

Does your child have a medical history of urinary tract infections. If so please explain

Name

Signature

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Date

Thank you for completing this form.

The information provided will be Saved to your client file.

Admin will be in contact to schedule your 1:1 with your OT, if not already scheduled. Your OT may email you subsquent forms for completion to enable data analysis at your meeting.

If you have any questions, please contact admin@tteam.com.au or call 02 9621 2504 who can help you further.