Pediatric Bowel & Bladder Screening

Pediatric Health History and Screen Questionnaire

Today's Date(Required)

Client's Information

When did this challenge begin?(Required)
Since this challenge began it has(Required)
Name of your child's last doctor visit(Required)
Date of last doctor visit(Required)
Date of last urinalysis(Required)
Previous tests for the for the condition that your child is coming to therapy
Please list the following for your child
Start Date
Reason for Taking
Has 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)
Please check all that your child has now or has had a history of
For all that you checked above please give the following:
Does your child have or had a history of Vesicoureteral reflux?(Required)

Bladder Habits

Does your child awaken wer in the morning?(Required)
How long does your child delay going to the toilet once they need to urinate? (Check one)(Required)
Does your child take time to go to the toilet and empty their bladder?(Required)
Does your child have difficulty intiating the urine stream?(Required)
Does your child strain to pass urine?(Required)
Does your child have a slow, stop/start or hesitant urinary stream?(Required)
The volume of urine passed is usually (check one)(Required)
Does your child have the feeling their bladder is still full after urinating?(Required)
Does your child have any dribbling after urination (once they stand up form the toilet)?(Required)
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
Does your child have "triggers" that make them feel like they can't wait to go to the toilet? (i.e. running water, etc)(Required)

Bowel Habits

Consistency of stool(Required)
Does your child currently strain to go?(Required)
Does your child ignore the urge to defecate?(Required)
Does your child have fecal staining on their underwear?(Required)
Does your child have a history of consipation?(Required)

Symptom Questionnaire

1. Bladder leakage (check all that apply)(Required)
2. Severity of leakage (check one)(Required)
3. Bowel leakage (check all that apply)

Responsible Party Information (Client or Parent/Guardian)