Client Intake Forms

Potty Training Boys

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Is your child in a bed or crib?
Is your child taking any medication (murilax, fiber, etc.)
Has your pediatrician cleared your child for potty training?
Does your child have any special needs?
Is your child in any type of OT, PT, or Early Intervention program for a developmental delay?
Does your child have any special needs?
Does your child have constipation issues?