Enuresis questionnaire

Jeffrey E. Lazarus, M.D.
Child & Adolescent Clinical Hypnosis & Biofeedback 1220 University Drive, Suite 104 — Menlo Park, California 94025 NOCTURNAL ENURESIS QUESTIONNAIRE
Nocturnal enuresis means urinating, wetting or “peeing” in the bed at night. Your answers to the following questions about this problem will help me to understand how best to help you with it. These questions are about you, the patient. Parents or guardians and children/adolescents can complete this form together. Circle, check or write in the answer that best tells about you. Young person’s name ___________________________________________ Preferred or nickname ___________________________________________ Special pronunciation ___________________________________________ Birth date _________________ Today’s date __________________ Person helping to complete this form ________________________________ 1. How old were you when you started urinating in the toilet during the day? 2. How many nights each week do you usually stay dry? 0 1 2 3 4 5 6 3. What is the longest you have ever been dry every night in a row? (Write in a number.) a. _____ Days b. _____ Weeks c. _____Months 4. Please check any and all of the following ways you have ever used to stay dry at night. Circle any of them you are using now. ____ Drinking little or less after dinner ____ Enuresis Alarm (Device that makes noise/vibrates when wet): Jeffrey E. Lazarus, M.D., a medical corporation 5. Have you ever used any of these medicines to treat enuresis? (Check all that apply) ____Imipramine (Tofranil) Dose:_______ ____Desmopressin (DDAVP) Dose:______ ____Oxybutinin (Ditropan) Dose:______ ____ Homeopathic medicine ____Herbal Substance: _______________________________ ____Other: _________________________________________ 6. Do you sometimes drink caffeinated drinks (soda, tea, coffee) during or after dinner? 7. When you need to urinate during the day, do you have to go right away ___Yes ___No 8. Do you sometimes urinate in your clothes by accident during the day? ___Yes ___No If “Yes” how many times each week? 1 2 3 4 5 6 7 more than 7 9. Do you sometimes have a bowel movement (BM, “poop”) in your clothes by accident during the day? ___Yes ___No If “Yes” how many times each week? 1 2 3 4 5 6 7 more than 7 10. Is it hard for you to have a bowel movement most days? ___Yes ___No 11. Do you take any medicine to help you have bowel movements most days? Yes No If “Yes,” what medicine(s)?________________________________________ 12. Do you have any other medical or health problems? ___Yes ___No If “Yes,” please check all that apply ____ Attention Deficit Disorder (ADD, ADHD) __________________________________________________________________ 13. Do you take any other medicines? ___Yes ___No If “Yes,” what medicine(s):_________________________________________ Jeffrey E. Lazarus, M.D., a medical corporation 14. Did either of your parents, or any uncles, aunts or cousins have enuresis as a child? ___Yes ___No 15. Is enuresis a problem for you? ___Yes ___No If “Yes,” check all reasons why it is a problem that fit for you, circle the most ____Have to wash my sheets/pajamas a lot _______________________________________________________________ Thank you for answering these questions. If there is more you want us to know, please write it here. If there are questions you want to make sure we answer for you, please write them here. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ You can also draw a picture if you like (there is more room on the back). From Olness, Karen, M.D., and Kohen, Daniel P., M.D., Hypnosis and Hypnotherapy with Children, The Gulford Press, 996 Jeffrey E. Lazarus, M.D., a medical corporation

Source: http://www.jefflazarusmd.com/downloads/enuresis_questionnaire.pdf