Thank you for getting started towards a very complete and educational evaluation. please fill out this form with as much information as possible about your situation. One of our staff will contact you shortly to start the evaluation.

1.Name of person with problem

2.Age

3.Name of person filling this out

Street Address

City

State

Zip code

You must enter  a phone number to get a response from the Clinic.

4.Telephone number

Best time to callTime zone

5.E-mail Address

6. Sex of enuretic? _ male female

7. Is there daytime wetting? _ yes no

8. Have you seen a doctor about bedwetting? _ yes no

9. Is medicine being taken for bedwetting? _ yes no

10. Is medicine being taken for other problems?  _ yes no

11. Please explain.

12. Do you notice a urgent need to urinate during the daytime? _ yes no

13. Do you feel they are a deep sleeper _ yes no

14. are they often difficult to wake up?  _ yes no

15. Have you ever used a moisture alarm?  _ yes no

16. Have you ever signed up with a bedwetting program _ yes no

17. Have you ever had another company sales person come to your home _ yes no

18. has there ever been dry nights?  _ yes no

19. What was the reaction when dry in the morning?

20. Do they seem to be a slow starter in morning?  _ yes no

21. would you say they have a short temper? _ yes no

22. Do you notice them suffering from being over active during day? _ yes no

23. Is there a noticeable short attention span?  _ yes no

24. Is there school problems? _ yes no

25. would they normally drink milk daily?  _ yes no

26. Have you tried any of the following:

Getting up at night?  Restricting liquids?

Offered rewards for not wetting? Scolding?

Diet adjustment?

Requiring chores to be done if wetting occurs?

27. Is bedroom on same level of house as your bedroom? _ yes no

28. What type of bed _ single double twin water Quenn king

29. Is there a urinary infection often? _ yes no

30. Do they have any of the following?

diabetes asthma allergies epilepsy

hearing problem speech problem

______________________________________

31. Is there any history of bedwetting in family?  _ yes no

32. what usually is the frequency of wetting at night? 1 _ 2 3 more then 3

33. Parents reason for wanting bedwetting problem corrected at this time.

34. The reason you feel the enuretic would like to end bedwetting for themselves.