Bladder Health Questionnaire - Advocare

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_________________________________________________________________________________________