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Bladder Health
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---------- Date of Birth ----------
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Last Name
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Male
Female
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
BLADDER HEALTH
Please answer the following questions regarding your bladder health.
How often do you urinate during the day?
2-3 times
6-8 times
more than 12
4-5 times
9-12 times
How often do you get up at night to urinate?
2-3 times
6-8 times
more than 12
4-5 times
9-12 times
Do you usually have a strong sense of urgency to urinate?
yes
no
Do you have pain or pressure in the bladder that is relieved by urinating?
yes
no
Can you postpone emptying your bladder easily?
yes
no
Can you overcome the sensation of urgency to urinate?
yes
no
Is your urinary flow intermittent (stop and go)?
yes
no
Does the sight, sound, or feel of running water cause you to lose your urine?
yes
no
Describe the nature of your leak.
(Mark all that apply.)
leak with urge (desire to void)
leak with coughing, sneezing, jumping, running, or lifting
leak without awareness
leak with intercourse
not applicable (no leakage)
continuous leakage
other
How much do you leak?
drops
"flood" (to the floor)
wet pants
not applicable (no leakage)
Do you find it necessary to wear protection because
you get wet from the urine that you lose?
yes
no
If yes, how many pads do you use daily?
1-2 pads
5-6 pads
more than 8 pads
3-4 pads
7-8 pads
Do you change the pad when it is:
damp
soaked
When urinating, can you usually stop your stream?
yes
no
Do you ever accidentally wet the bed at night while asleep?
yes
no
If yes, how often?
rarely
occasionally
once a week
twice a week
more than twice a week
nightly
Do you feel that you completely empty your bladder?
yes
no
Do you notice dribbling of urine when you stand after urinating?
yes
no
Were you ever catheterized because you were unable to void?
yes
no
Have you ever been treated by urethral dilations?
yes
no
Do you ever pass blood in your urine?
yes
no
Have you ever passed sand, gravel, or stones?
yes
no
Do you have pain during urination?
yes
no
Do you have difficulty starting your stream?
yes
no
How do you start your flow?
easy
push / strain
wait less than one minute
wait more than one minute
Have you been treated for 3 or more urinary infections?
yes
no
Have you been treated for a bladder infection within the last 6 months?
yes
no
BOWEL HEALTH
Please answer the following questions regarding your bowel health.
How would you describe your bowel movements?
normal
constipated
loose
Have you ever passed stool when you thought it might be gas?
yes
no
If yes, how often?
once
twice
occasionally
often
GENERAL HEALTH
Do you have (or had in the past) any of the following?
(Mark all that apply.)
arthritis
heart problems
sleep apnea
stroke
back injury
asthma
vaginal bulge (prolapse)
multiple sclerosis
diabetes
NONE
WOMEN'S HEALTH
Women Only: Please answer the following questions regarding your health.
How many live births have you had?
NONE (No live births)
1
2
3
4
5
6
7
8
9
10
C-SECTION
1
2
3
4
5
6
7
8
9
10
NATURAL
Did your urinary difficulty begin:
During a pregnancy?
yes
no
Following a pregnancy?
yes
no
Have you had a hysterectomy?
yes
no
If yes, was it vaginal?
yes
no
Or abdominal?
yes
no
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