Bladder Health Questionnaire - Advocare

Bladder Health Questionnaire
Please bring this form with you on the day of your appointment.
Name______________________________________________________ Date: _____________________________
Last menstrual period: ____________ Allergies: ______________________________________________________
Please write in your own words, the nature of your current problem.______________________________________
_____________________________________________________________________________________________
When did your bladder problems begin?
How often do you urinate during the day/evening?
How often do you get up at night to urinate?
_____________________
_____________________
_____________________
How would you rate the effect of your leakage on your lifestyle?
Little or no impact
_____
Somewhat bothersome
_____
Severely interferes with my lifestyle
_____
Yes No Sometimes
When urinating, do you feel you have completely emptied your bladder? ___ ___ ___
When urinating, can you stop your stream? ___ ___ ___
Can you postpone emptying your bladder easily? ___ ___ ___
Do you experience pain when your bladder is full? ___ ___ ___
Do you have pain when emptying your bladder? ___ ___ ___
Do you usually have a strong sense of urgency to urinate? ___ ___ ___
Do you ever wet your bed at night? ___ ___ ___
Do you notice dribbling of urine after emptying your bladder? ___ ___ ___
Do you lose urine when:
You are lying down or asleep? ___ ___ ___
You sneeze, cough, jump, run, or laugh? ___ ___ ___
You get up from a sitting position? ___ ___ ___
You hear, see or feel running water? ___ ___ ___
You can’t get to the bathroom on time? ___ ___ ___
You don’t even know it? ___ ___ ___
Do you wear protection for urinary leakage? ___ ___ ___
If yes, do you use:
Panty liners ___ ___ ___
Shield-type pads ___ ___ ___
Briefs ___ ___ ___
Underwear ___ ___ ___
If yes, how many do you wear per day? _______________
Do you have difficulty starting your urine stream? ___ ___ ___
How do you start your urine stream?
Easy
_____
Push/strain
_____
Wait less than 1 minute
_____
Wait more than one minute _____
2110 Ark Rd. Ste. 216
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Columbus, NJ 08022
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advocareBCOBGYN.com
12.2011

Have you ever had a tube placed in your bladder because you were
unable to empty you bladder? ___ ___ ___
Have you ever had your urethra dilated or stretched? ___ ___ ___
Have you ever passed blood in your urine? ___ ___ ___
Have you ever had a kidney or bladder infection? ___ ___ ___
Have you been treated for three or more urinary tract infections? ___ ___ ___
Yes No Sometimes
Have you had an infection within the last 6 months? ___ ___ ___
Do you notice a bulge or anything protruding from your vagina? ___ ___ ___
Do you leak gas or stool? ___ ___ ___
Are you constipated? ___ ___ ___
Do you have to push on your vagina to have a bowel movement? ___ ___ ___
What treatments for your bladder problems have you tried in the past?
Kegel exercises
_____
Pessary insertion
_____
Fluid/diet changes
_____
Medications
_____
List them ________________________________________________________
Surgery (list below)
_____
Collagen injections
_____
List all the medications you have been taking over the last 6 months:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you take aspirin? ___ ___ ___
If yes, how often?
___________
How many pregnancies have you had? ____
Vaginal deliveries? ___ C-section deliveries? ___ Miscarriages? ___
How many caffeinated beverages do you drink daily?
How many cigarettes do you smoke each day?
When was the last time you had sexual intercourse?
Do you have pain during intercourse?
____
____
____
____
List all the surgeries you have had and the dates of each:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have the following?:
____ Heart problems/Murmurs
____ Multiple sclerosis
____ Diabetes
____ High blood pressure
____ Parkinson’s Disease
____ Liver Disease
____ Asthma/Lung Problems
____ Stroke
____ Kidney Disease
____ Arthritis
____ Glaucoma
____ Blood Clots
Back injury (when and what) ______________________________________________________________________
Other_________________________________________________________________________________________