Home   Enuresis (Bedwetting) Questionnaire

Enuresis (Bedwetting) Questionnaire

PLEASE PRINT AND COMPLETE. Bring the completed form with you to discuss at your next office visit.

 

  1. Has your child ever been completely dry (day and night) for at least 3 consecutive months? Y/N 
  2. Does your child have any of the following symptoms: 
    1. Difficulty urinating
    2. Difficulty urinating with a good stream
    3. History of a Urinary tract infection
    4. Complain of burning with urination
    5. History of blood in their urine
    6. Urinary urgency
    7. Urinary frequency
    8. Constipation
    9. Diarrhea
    10. Fecal Soiling
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N

     

  3. Does your child have urinary incontinence? Y/N 
    • Wet during the dayIf yes, # of times per day:

      and # of times per week:

       

    Y/N
    • Wet during the nightIf yes, # of times per week:

       

    Y/N

     

  4. Is your child a deep sleeper? Y/N 
  5. Which of the following treatments, if any, have you tried and have they been successful in stopping the wetting? 
    TreatmentFluid restrictions
    Nighttime awakening
    Punishment
    Rewards/Praise
    Bell Alarm
    Medication (such as DDAVP)
    Diet changes
    Therapy/Counseling
    Surgery
    SuccessfulY/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N
    Y/N

Child’s Name ____________________________________________