Pelvic Health OT Health History & Screening Questionnaire

Pediatric Health History & Screening Questionnaire

This screening document is used to determine if your child is a good candidate for pediatric pelvic health OT. Our therapist Miss Trisha will review the form and contact you within 3 business days to discuss results and/or schedule an initial evaluation if the child qualifies.
Child's Full Name:*
Child's Date of Birth:*

MonthDayYear
Date
Height (in inches):*
Weight (pounds):*
Parent name:*

First NameLast Name
Parent phone number:*
Please enter a valid phone number.
Home address:*
School name:*
Grade:*
Special program?*
What are your primary concerns?*
When did this problem begin?*
Since it began, is the problem:*

Getting betterStaying the sameGetting worse
Date of child's last doctor visit:*

MonthDayYear
Date
Date of last urinalysis:*

MonthDayYear
Date
Please list any other related testing procedures & results:*
Medications:*
Start date*

MonthDayYear
Date
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 play dates.)*
Does your child currently have or has had a history of the following?*

Pelvic painLow back painKidney infectionsBladder infectionsVesicoureteral refluxAllergiesAsthmaPhysical abuseBlood in urineBlood in fecesDiabetesLatex sensitivity or allergyNeurological conditionSurgeriesSexual abuse
Please explain yes responses and include dates:
Does your child need to be catheterized?*

YesNo
If yes, how often?
Bladder Habits
1. How often does your child urinate during the day?
blanks* times per day
everyblank* hours
2. How often does your child wake up to urinate after going to bed?
blanks* times per night
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 all1-2 minutes3-10 minutes11-30 minutes31-60 minutesHours
6. Does your child take time to go to the toilet and empty their bladder?*

YesNo
7. Does your child have difficulty initiating the urine stream?*

YesNo
8. Does your child strain to pass urine?*

YesNo
9. Does your child have a slow, stop/start or hesitant urinary stream?*

YesNo
10. Is the volume of urine passed usually:*

LargeAverageSmallVery small
11. Does your child have the feeling their bladder is still full after urinating?*

YesNo
12. Does your child have any dribbling after urination; i.e. once they stand up from the toilet?*

YesNo
13. Fluid intake (one glass is 8 OZ or one cup)
blanks* glasses per day
blank* glasses of caffeinated drink per day
Typical types of drinks they prefer:*
14. Does your child have "triggers" that make them feel like they can't wait to go to the toilet? (i.e. running water, etc.)*

YesNo
If yes, please explain:
Bowel Habits
15. Frequency of bowel movements:
blanks* times per day
blank* times per week
16. Consistency of bowel movements:*

LooseNormalHard
17. Does your child currently strain to go?*

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

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

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

YesNo
21. If yes, how long has it been a problem?*
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 bedwetting
2a. Frequency of urinary leakage-number (#) of episodes:
blanks* times per month
blank* times per week
2b. Frequency of urinary leakage-number (#) of episodes:
blanks* times per day
blank* constant leakage
3. Severity of bladder leakage (check 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
5a. Frequency of bowel leakage-number (#) of episodes:
blanks* times per month
blank* times per week
5b. Frequency of bowel leakage-number (#) of episodes:
blanks* times per day
6. Severity of bowel leakage (check one):*

No leakageStool stainingSmall amount in underwearComplete emptying
7. Leak protection used (check all that apply):*

NoneTissue paper/paper towelDiaperPull-ups
8. Please ask your child to rate his/her feelings as to the severity of this problem from 0 (not a problem) to 10 (major problem): *
9. Please rate the following statement as it applies to your child's life today: "My child's bladder is controlling his/her life." 0 (not true at all) to 10 (completely true)*
Should be Empty:

Bladder Habits

Bowel Habits

Symptom Questionnaire