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  • 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.

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  • Bladder Habits

  • 1. How often does your child urinate during the day?
    * times per day
    every* hours

  • 2. How often does your child wake up to urinate after going to bed?
    * times per night

  • 13. Fluid intake (one glass is 8 OZ or one cup)
    * glasses per day
    * glasses of caffeinated drink per day

  • Bowel Habits

  • 15. Frequency of bowel movements:
    * times per day
    * times per week

  • Symptom Questionnaire

  •  2a. Frequency of urinary leakage-number (#) of episodes:
    * times per month
    * times per week

  •  2b. Frequency of urinary leakage-number (#) of episodes:
    * times per day
    * constant leakage

  •  5a. Frequency of bowel leakage-number (#) of episodes:
    * times per month
    * times per week

  •  5b. Frequency of bowel leakage-number (#) of episodes:
    * times per day

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  • Should be Empty: