The Bedwetting Solution

A Family Centered Ministry

 

 

 

 

Please take a little time and learn more about this deep sleep disorder.

If you would like to call and have one of our staff explain more on this subject then call

(989) 634-8400.

To learn more about the free evaluation click here.

 

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?

7. Is there daytime wetting?

8. Have you seen a doctor about bedwetting?

9. Is medicine being taken for bedwetting?

10. Is medicine being taken for other problems? 

11. Please explain.

12. Do you notice a urgent need to urinate during the daytime?

13. Do you feel they are a deep sleeper

14. are they often difficult to wake up? 

15. Have you ever used a moisture alarm? 

16. Have you ever signed up with a bedwetting program

17. Have you ever had another company sales person come to your home

18. has there ever been dry nights? 

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

20. Do they seem to be a slow starter in morning? 

21. would you say they have a short temper?

22. Do you notice them suffering from being over active during day?

23. Is there a noticeable short attention span? 

24. Is there school problems?

25. would they normally drink milk daily? 

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?

28. What type of bed

29. Is there a urinary infection often?

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? 

32. what usually is the frequency of wetting at night?

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.

 

         

Please take a little time and learn more about this deep sleep disorder. If you would like to call and have one of our staff explain more on this subject then call (989) 634-8400. For information by e-mail click here. For e-mail information please tell us about your situation.