Pediatric Incontinence & Toileting Questionnaire

Pediatric Incontinence & Toileting Questionnaire
Patient History and Symptoms
Parent/Guardian Name*
Child’s name*
Prefers to be called
Date of Birth*

MonthDayYear
Date
Age*
Grade
Height*
Weight*
Describe the reason for your child’s appointment*
When did this problem begin?*
This problem is:*

Getting betterworsestaying the same
Date of child’s last doctor visit*

MonthDayYear
Date
Date of last urinalysis

MonthDayYear
Date
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.

Pelvic painLow back painDiabetesLatex sensitivity/allergyAllergiesAsthmaSurgeriesBlood in urineKidney infectionsBladder infectionsVesicoureteral refluxMeurologic (brain, nerve) problemsPhysical or sexual abuseOther
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?*

YesNo
If yes, how many days per week?
4. Does your child have the sensation (urge feeling) that they need to go to the toilet?*

YesNo
5. How long does your child delay going to the toilet once he/she needs to urinate?*

Not at all11-30 minutes1-2 minutes31-60 minutes3-10 minutesHours

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:*

LargeAverageSmallVery small
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*

loosenormalhard
2. Does your child strain to go?*

YesNo
3. Does your child ignore the urge to defecate?*

YesNo
4. Does your child have fecal staining on their underwear?*

YesNo
How often?
5. Does your child have a history of constipation?*

YesNo
Symptom Questionnaire
1. Bladder leakage (Check all that apply)*

NeverWhen playingWhile watching TV or video gamesWith strong cough/sneeze/physical exerciseWith a strong urge to goNighttime sleep wetting
2. Frequency of urinary leakage (number of episodes):*

# per month# per week# per dayconstant leakage
Frequency # amount
3. Severity of leakage (select one)*

No leakageFew dropsWets underwearwets outer clothing
4. Bowel leakage (Check all that apply)*

NeverWhen playingWhile watching TV or video gamesWith strong cough/sneeze/physical exerciseWith a strong urge to go
5. Frequency of bowel leakage (number of episodes):

# per month# per week# per dayconstant leakage
Frequency # amount
6. Severity of leakage (circle one)*

no leakagestool stainingsmall amount in underwearcompletely emptying
7. Protection worn (circle all that apply)*

nonetissue paper/paper toweldiaperpull-ups
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