Age-friendly Primary Health Care Centres Toolkit - World Health ...

AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITWhat for ?By whom ?How long ?Tool 5: Urinary incontinence evaluation formUrinary incontinence evaluationPart 1: Nurse or trained health care workerPart 2: Medical doctor15 minutesPART 1Name:_______________Age:_______________ Date:________________Genitourinary history.Bladder tumor Recurrent UTI Kidney stones Prostate problemWomen onlyN° of Pregnancies ____Menopause? Y/N How long?______Estrogens Y/NFamily history cancer breast Hysterectomy Ovaries removedSummary of incontinenceWhen did the problem begin?Does it influence with your activities of daily living?If yes, how?What makes the problem worse?Running Sneeze, cough Laugh Lift Bending downRunning waterWhat problems do you have with passing your urine? (adapt culturally) Starting Slow stream Discomfort59