UPDOX - PATIENT PORTAL

Bed Wetting Questionnaire

These questions are about you, the patient. Parents or guardians and children can complete this form together. Circle, check or write in the answer to best tell us about you.

Patients name * Patients Date Of Birth: * Today's date * Person helping to complete this form: * How old were you when you started urinating in the toilet during the day * How many nights each week you usually stay dry? * What is the longest you have ever been dry every night in a row? * Please check any and all of the following ways you have every used to stay dry at night. * have you ever used any of these medicines to treat enuresis? ( check all that apply) * Do you sometimes drink caffeinated drinks during or after dinner? * When you need to urinate during the day, do you have to go right away? * Do you sometimes urinate in your clothes by accident during the day * If yes how many times per week? Do you sometimes have a bowel movement (poop) in your clothes by accident during the day? * If yes how many times per week? Is it hard for you to have a bowel movement most days? * Do you take any medicines to help you have bowel movements most days? if yes what medicine? * Dou you have any other medical or health problems? * Do you take any other medicines? If yes what medication? * Did either of your parents, aunts, uncles, or cousins have enuresis as a child? If yes who? * Is enuresis a problem for you? * If yes check all reasons why it is a problem for you * please explain any other reasons this is a problem for you if not listed above * Thank you for answering these questions. If there is more that you would like for us to know, please write it here If there are questions you want to make sure we answer for you, please write them here.