Bladder Health

 

Please answer the following questions regarding your bladder health.

 
How often do you urinate during the day?
 
 
 
 
 

How often do you get up at night to urinate?
 
 
 
 
 

Do you usually have a strong sense of urgency to urinate?
 
 

Do you have pain or pressure in the bladder that is relieved by urinating?
 
 

Can you postpone emptying your bladder easily?
 
 

Can you overcome the sensation of urgency to urinate?
 
 

Is your urinary flow intermittent (stop and go)?
 
 

Does the sight, sound, or feel of running water cause you to lose your urine?
 
 

Describe the nature of your leak (mark all that apply).
 
 
 
 
 
 
 

How much do you leak?
 
 
 
 

Do you find it necessary to wear protection because you get wet from the urine that you lose?
 
 
 
How many pads do you use daily?
 
 
 
 
 
Do you change the pad when it is:
 
 

When urinating, can you usually stop your stream?
 
 

Do you ever accidentally wet the bed at night while asleep?
 
 
 
How often?
 
 
 
 
 
 

Do you feel that you completely empty your bladder?
 
 

Do you notice dribbling of urine when you stand after urinating?
 
 

Were you ever catheterized because you were unable to void?
 
 

Have you ever been treated by urethral dilations?
 
 

Do you ever pass blood in your urine?
 
 

Have you ever passed sand, gravel, or stones?
 
 

Do you have pain during urination?
 
 

Do you have difficulty starting your stream?
 
 

How do you start your flow?
 
 
 
 

Have you been treated for 3 or more urinary infections?
 
 

Have you been treated for a bladder infection within the last 6 months?
 
 
 

Bowel Health

 

Please answer the following questions regarding your bowel health.

 
How would you describe your bowel movements?
 
 
 

Have you ever passed stool when you thought it might be gas?
 
 
 
How often?
 
 
 
 
 

General Health

 
Do you have (or had in the past) any of the following (mark all that apply)?
 
 
 
 
 
 
 
 
 
 
 

Women's Health

 

Please answer the following questions regarding your health.

 
How many live births have you had?
 
C-Section
 
 
 
 
 
 
 
 
 
 
Natural
 
 
 
 
 
 
 
 
 
 

Did your urinary difficulty begin:
 
During a pregnancy?
 
 
Following a pregnancy?
 
 

Have you had a hysterectomy?
 
 
 
Was it vaginal?
 
 
Or abdominal?
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 775
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.