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Bed Wetting - Patient Portal
Bed Wetting - Patient Portal
Complete your questionnaire and track measurements
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עברית
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Patient Identification and Details
Full Name
ID Number
Date of Birth
Age
-- years
Gender
Select Gender
Male
Female
Other
Weight (kg)
Height (cm)
BMI
--
Address Line 1
City
County
Phone Numbers
Add Phone
No phone numbers added. Click "Add Phone" to add one.
Treatment History and Medications
Previous treatments performed:
Nighttime wake-up by family member
Absorbent underwear
Conditioning therapy
Psychological therapy
Medication Treatment:
Oxytocin
Novitropan
Spasmex
Detrusitol
Minirin Melt
Minirin Tab
Alternative Medications
Bedwetting Diagnosis and Family History
Wetting Type
Primary
Secondary
Fecal Leakage
Was dry for (period)
Can hold during daytime?
Select...
Yes
No
Number of wettings per month
Number of wake-ups per month
Nighttime Urine Output
Select...
Small (underwear)
Medium (clothes)
Large (entire bed)
Who wet in the family?
Father
Mother
Siblings
Grandparents/Uncles
Sleep Depth Assessment
Sleep Depth - Child (1-10)
1
10
Sleep Depth - Father (1-10)
1
10
Sleep Depth - Mother (1-10)
1
10
+ Add Sleep Depth (Additional Family Member)
Sleep Monitoring
Goes to sleep at
Wakes up at
Sleep Hours
--:--
Is there a difference in sleep times between regular days and:
Weekends
Holidays
School
Work
Does sleep during the day?
No
Yes
Sleep Quality
How long does it take to fall asleep?
Wake-ups during the night?
No
Yes
Difficulty returning to sleep?
No
Yes
Continuous / Interrupted sleep
Continuous
Interrupted
Behavior Around Sleep
Bedtime resistance
Need for parent presence
Regular routine
Screen use before sleep
Sleep Environment
Sleep Location
Own bed
Shared
Other
Lighting
No
Yes
Noise, Temperature
Screens in room (phone, TV)
No
Yes
Daytime Function
Difficulty waking in the morning
No
Yes
Fatigue during the day
No
Yes
Unplanned sleep
No
Yes
Concentration, mood, behavior at school
Warning Signs Requiring Attention
Loud snoring or breathing pauses
No
Yes
Nightmares or night terrors
No
Yes
Sleepwalking
No
Yes
Nighttime wetting (if present)
No
Yes
Medical/Developmental Data
Regular medications
ADHD, anxiety, medical problems
Recent changes (move, stress, illness)
Motor Development
Rolled over at age
Sat at age
Crawled at age
Stood at age
Walked at age
At what age stopped bowel movements in diaper?
At what age was daytime bowel trained?
Update Medical Record