Pediatric Bowel & Bladder Screening Pediatric Health History and Screen Questionnaire Today's Date(Required) Month Day Year Client's InformationName(Required) First Name(Required) Last Age(Required)Grade(Required)Height(Required) Weight(Required) Describe the reason for your child's appointment(Required) When did this challenge begin?(Required) Month Day Year Since this challenge began it has(Required) Gotten better Gotten worse Stayed the same Name of your child's last doctor visit(Required) First Last Date of last doctor visit(Required) Month Day Year Date of last urinalysis(Required) Month Day Year Previous tests for the for the condition that your child is coming to therapyTestResult Add RemovePlease list the following for your childMedicationsStart DateReason for Taking Add RemoveHas your child stopped or been unable to do certain activities because of their condition? For example embarrassed to play with friends, can't go on sleepovers, feels ashamed about leakage and avoids play dates.(Required) Yes No If Yes, please describe: Please check all that your child has now or has had a history of Pelvic pain Low back pain Diabetes Latex sensitivity/allergy Allergies Asthma Surgeries Blood in urine Kidney infections Bladder infections Neurologic (brain, nerve) problems Physical or sexual abuse For all that you checked above please give the following:ExplainDates Add RemoveDoes your child have or had a history of Vesicoureteral reflux?(Required) Yes No If yes, what grade? Bladder HabitsHow many times per day does your child urinate?(Required) How many times does your child urinate each hour?(Required) How many times does your child wake up to urinate after going to bed?(Required) Does your child awaken wer in the morning?(Required) Yes No If yes, how many days per weekHow long does your child delay going to the toilet once they need to urinate? (Check one)(Required) Not at all 1-2 minutes 3-10 minutes 11-30 minutes 31-60 minutes Hours Does your child take time to go to the toilet and empty their bladder?(Required) Yes No Does your child have difficulty intiating the urine stream?(Required) Yes No Does your child strain to pass urine?(Required) Yes No Does your child have a slow, stop/start or hesitant urinary stream?(Required) Yes No The volume of urine passed is usually (check one)(Required) Large Average Small Very Small Does your child have the feeling their bladder is still full after urinating?(Required) Yes No Does your child have any dribbling after urination (once they stand up form the toilet)?(Required) Yes No Fluid intake (one glass is 8 oz. or one cup)(Required)Number of glasses per day (all types of fluid)Number of glasses per day of caffeinated beverages Add RemoveDoes your child have "triggers" that make them feel like they can't wait to go to the toilet? (i.e. running water, etc)(Required) Yes No If yes, please list Bowel HabitsFrequency of movements per a day?(Required)Frequency of movements per a week?(Required)Consistency of stool(Required) Loose Normal Hard Does your child currently strain to go?(Required) Yes No Does your child ignore the urge to defecate?(Required) Yes No Does your child have fecal staining on their underwear?(Required) Yes No If yes, how often? Does your child have a history of consipation?(Required) Yes No If yes, how long have they had a history of constipation? Symptom Questionnaire1. Bladder leakage (check all that apply)(Required) Never When playing While watching TV or video games With strong cough/sneeze/physical exercise With a strong urge to go Nighttime sleep wetting 2. Severity of leakage (check one)(Required) No leakage Few drops Wets underwear Wets outer clothing 3. Bowel leakage (check all that apply) Never When playing While watching TV or video games With strong cough/sneeze/physical exercise With a strong urge to go Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) Last Phone(Required)Email(Required)
