Pediatric Incontinence & Toileting Questionnaire

Pediatric Incontinence & Toileting Questionnaire
Please Note: Every question included in this intake is used to adequately prepare for your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's First and Last Name:
Prefers to be called
Child's Birth Date:

MonthDayYear
Parent/Guardian 1 Name:
Relationship to child
Parent/Guardian 1 Cell Phone Number

Area CodePhone Number
Please send me text reminders:
I would like my reminder:
Parent/Guardian 1 Email address:
Parent/Guardian 1 Date of Birth:
Parent/Guardian 2 Name:
Relationship to Child
Parent/Guardian 2 Cell Phone Number

Area CodePhone Number
Parent/Guardian 2 Email Address:
Parent/Guardian 2 Date of Birth:
Who has legal custody of the child?

Other
Who is legally authorized to make health care/therapy decisions for the child?

Other
Is there a court order, custody agreement, guardianship document, Delegation of Parental Authority (DOPA), or other legal document that affects who may make health care decisions or receive information about this child?
Please upload any applicable documents:

Cancelof
Is anyone other than a parent or legal guardian authorized to make health care/therapy decisions for this child?
If yes, please provide their name
Relationship to the child
Type of Legal Authority (please provide a copy of the current documentation via email or fax)

Other
Are there any restrictions on contacting or providing information to any parent, guardian, or other individual associated with this child?
Please explain
Please provide documentation (if different from above upload)

Cancelof
If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.
Patient History and Symptoms
Grade
Height
Weight
Describe the reason for your child’s appointment
When did this problem begin?
This problem is:
Date of child’s last doctor visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of last urinalysis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous tests for the condition for which your child is coming to therapy. Please list tests and results
Medications: please list start date and 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 playdates? Please explain.
Does your child now have or had a history of the following? Explain all "yes" responses below.

Other
Explanation of above history (e.g., surgery, bladder infections).
Bladder Habits
1.How often does your child urinate during the day?
frequency times per day, every frequency* hours
2. How often does your child wake up to urinate after going to bed?
3. Does your child awaken wet in the morning?
If yes, how many days per week?
4. Does your child have the sensation (urge feeling) that they need to go to the toilet?
5. How long does your child delay going to the toilet once he/she needs to urinate?

Does your child

Rows	Yes	No
Take time to go to the toilet and empty their bladder
Have difficulty initiating the urine stream
Strain to pass urine
Have a slow, stop/start or hesitant urinary stream
Have the feeling their bladder is still full after urinating
Have any dribbling after urination (i.e., once they stand up from the toilet)
Have trigger that make them feel like they can't wait to go to the toilet (e.g., running water)

List any triggers from above
10. The volume of urine passed is usually:
Typical Fluid Intake
Number of glasses per day (all types of fluid)*
Number of caffeinated glasses per day *
Typical types of drinks:
Bowel Habits
1.Frequency of bowel movements
times* per day
times* per week.
Consistency
2. Does your child strain to go?
3. Does your child ignore the urge to defecate?
4. Does your child have fecal staining on their underwear?
How often?
5. Does your child have a history of constipation?
Symptom Questionnaire
1. Bladder leakage (Check all that apply)
2. Frequency of urinary leakage (number of episodes):
Frequency # amount
3. Severity of leakage (select one)
4. Bowel leakage (Check all that apply)
5. Frequency of bowel leakage (number of episodes):
Frequency # amount
6. Severity of leakage (circle one)
7. Protection worn (circle all that apply)
8. Ask your child to rate their feelings as to the severity of this problem

1

2

3

4

5

6

7

8

9

10

1 is Not a problem, 10 is Major problem
9. Rate the following statement as it applies to your child's life today: My child's bladder is controlling their life

1

2

3

4

5

6

7

8

9

10

1 is not true at all, 10 is completely true
Should be Empty:

Pediatric Incontinence & Toileting Questionnaire

Patient History and Symptoms

Bladder Habits

Bowel Habits

Symptom Questionnaire