Preliminary Diagnosis Questionnaire - Bed-Wetting

This questionnaire enables us to determine the adequacy of our treatment approach to your child. It also enables us to answer specific questions that you might have regarding your child’s wetting problem.
Please provide as much information as possible, it will enable us to study the problem and submit our reply to you.

Personal Details

1.Parents wake up child to void during the night
2. Parents impose drinking limit before bed-time?
3.Parents insist on voiding before bed-time.
4.Parents offer rewards for dry nights?
5.Frequency of bed wetting
6.Wetting occurs :
7.Is there also a soiling problem ?
8.Has there been a period of at least 6 consecutive months during which the child was completely dry ?
9.Sleep pattern
10.The child's motivation to be dry
11.School / Education program
12.Child functioning at school or kindergarten
13.Social interaction
14.General health condition
15.Bed Wetting history with uncles/aunts beyond the age of 5
17.Bed Wetting history with siblings beyond the age of 5
18.Has the child received any professional treatment for bed wetting (check the appropriate box)
19.Bed Wetting history with either parent beyond the age of 5
20.General comments
21.Please type the Security Text below
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