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ASSESSMENT FORM

By Completing the following questionnaire you can understand your own situation better. This information will be used for general statistical purposes for research to enable our mission of improving the management of Enuresis. The information provided is kept confidential. . This will only be used in direct contact with you. This information will not be shared with mailing list providers.

We will get back to you with the assessment results.

General Information

* Compulsory Fields

Your First Name: *
Last Name:
Child's Name:
Email Address: *
Street Address:
City:
State:
Zip/Pin:
Country:
Telephone Number:
Mobile Number

Details of the Child with Bedwetting

Age   in years *
Gender  
Bedwetting since birth, with not more than 6 months of dryness  
Does the child wet every night?  
How many times a night?  
Does the child flood the bed?  
What is the longest period of dryness?  
Has the child ever had urine infection?  
Does the child wakeup after wetting?  
Can the child wake to an alarm clock?  
Are there daytime symptoms of wetting, urgency, or frequency?  
How much fluids does the child drink?  
Does the child snore?  
Is the child constipated?  
Is there a history of bedwetting in the parents or other close relatives?  
Does the child’s bedwetting present social problems outside the home?  
Is the child’s self-esteem otherwise affected by the bedwetting?  
What is attitude of the parents to this problem?  
Is there anything in the child’s life such as an illness or emotional problem that may be contributing to the problem?  
Is the child keen to be dry?  
In your opinion, what the is reason for your child’s bedwetting?  

Doctors Consulted

(check any that apply)

Family doctor Pediatrician Urologist

What advice were you given? (check any that apply)

Urine tests

Medicines

Bedwetting Alarm

 

Methods You Have Tried

(check any that apply)

Restricting Fluids

Lifting up the child at night

Set Alarm Clock for the child

Set Alarm Clock for the parents

Rewarding dry nights 

Punishment

Child to help in laundry

Dry/wet nights records

Bedwetting Alarm

Length of time dry with alarm: weeks

Other Methods Tried:

* Compulsory Fields

    

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