Download Nephrology Questionnaire

Children’s Kidney and Bladder Center
516-663-9494
Patient:
D.O.B.:
Filled out by:
Relationship:
Referring Dr:
_
Male/Female
Dr’s Phone #: ___________________
INSTRUCTIONS: These questions are designed to help obtain information about
the health of your child. Some of the questions may be inappropriate for your child and
may be left unanswered. Please answer the questions by circling “YES” or “NO” or by
writing in the requested information.
HISTORY OF PRESENT ILLNESS
1. What is the main problem(s) for which your child is being seen at the Children’s
Kidney and Bladder Center?
2. Please describe how and when the present problem was detected/started; please
include the dates and results of any laboratory tests (sonogram/x-ray studies) that were
obtained.
MD Signature:___________________
Date:_________________
1
Patient Name:______________________
D.O.B.:_______________
3. Please list any other problem(s) and concern(s):
4. Please list the medications that your child is taking:
HISTORY OF KIDNEY AND URINARY TRACT PROBLEMS
5.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
6.
7.
Has this child had:
Blood in urine on lab testing
Brown urine
Protein in urine
Joint pain or joint swelling
Skin rash
Recent sore throat
Swelling of legs
Recent fevers/mouth sores/weight loss
High blood pressure
Headaches
Does this child :
a. pass urine 3 times or less in a day
b. not void within one 1 hour of awakening
c. hold urine for more than 12 hours overnight
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
YES
YES
YES
Has this child ever had:
a. Constipation, Bowel movements once in 3 days or less often
b. Has this child ever manifested stool withholding or stool leakage
8.
a.
b.
c.
d.
Has this child ever had:
Bedwetting beyond age 4 years
Increased urinary frequency
(every 2 hours or more often)
Sudden uncontrollable urgency of urination
Leakage of urine in the day
MD Signature:___________________
NO
NO
YES
YES
NO
NO
YES
YES
Date:_________________
2
NO
NO
YES
YES
Patient Name:______________________
e.
f.
g.
h.
i.
j.
D.O.B.:_______________
Painful urination
Foul smelling urine
Urinary infection
Inability to start or delay in starting urination
Feeling of incomplete bladder emptying
A weak or interrupted urine stream
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
9. Does this child have obstructive sleep apnea or snoring? NO
YES
ANSWER QUESTIONS #10-30 ONLY IF YOU ANSWERED YES TO ANY PART OF
QUESTION ON PART #8 OTHERWISE SKIP TO QUESTION #32 ON PAGE 6
10. At what age was this child able to initiate urination on the potty
11. At what age was the child off diapers during the day
12. At what age did he/she achieve night time dryness
13. At what age was this child toilet trained for stools
14. Does this child currently urinate more frequently than every
2 hours in the day
NO
15. What is the longest time (in hours) that this child can go
without urinating in the daytime?
(think of car trips or sitting through a movie)
16. Does this child ever leak urine during the day-even
a few drops or has damp underwear?
How often does this occur? A. daily
B. every other day
YES
_____
NO
YES
C.
17. When this child gets the urge to urinate can he/she (circle one)
a. Cannot suppress the urge and urine often leaks out
b. Cannot suppress and must run to the bathroom
c. Can suppress the urge and delay going to the bathroom
NO
NO
NO
YES
YES
YES
18. Does this child have an urge to urinate minutes after
he/she finishes urination?
NO
YES
MD Signature:___________________
Date:_________________
3
Patient Name:______________________
D.O.B.:_______________
19. If urine leaks, what is used to protect the child’s clothing?
(circle all that apply)
a. None needed
b. Tissue paper
c. Diapers
d. Sanitary pads
e. Change underpants
f. Change clothes
20. Does this child leak on (circle all that apply)
a. Coughing b. Giggling
c. Sneezing
d. Jumping
21. Does this child try to actively hold back urine
If so, does this child: (circle all that apply)
a.
Squeeze his/her legs together
b.
Sit on foot/ankle
c.
Press on the external genitals
d.
Other
NO
YES
24. Is it hard to initiate urination (seems to take a long time
before the urine will start to flow?)
NO
YES
25. Does he/she have to strain or put manual pressure on the
bladder to aid urination?
NO
YES
26. After urinating does he/she have a feeling that the
bladder is not completely empty?
NO
YES
22. At what age did this child start with acts of holding back urine?
23. How do you describe this child’s stream of urine?
a. Normal
b. weak
c. stop and start
27. Does this child wet the bed at night? (If no, skip to question #31 on page 5)
a. What time does the child go to sleep?
_____
b. At what time(s) of the night does he/she wet?
c. How many nights in a week does the child wet the bed?
d. What has been the longest period of dry nights?
e. Does the child wet the bed several times a night?
NO
f. If this child is taken to the bathroom at midnight,
would he/she still wet the bed?
NO
g. Does he/she wake up after wetting to change pajamas?
NO
h. Does he/she snore during sleep?
NO
MD Signature:___________________
Date:_________________
4
YES
YES
YES
YES
Patient Name:______________________
D.O.B.:_______________
28. Does this child awaken spontaneously to empty the bladder
during the night?
a.
At what time of the night?
b.
How often in a week / month?
NO
29. Were any of the following measures used to help the bedwetting?
a.
Restriction of fluids after supper?
b.
Use of alarm clock?
c.
Use of a commercial bedwetting alarm?
d.
Medications (name, dose and duration, if known)
e.
Did any of the above measures help?
if yes, which?
YES
NO
NO
NO
NO
YES
YES
YES
YES
NO
_____
YES
30. Please circle the number below which best describes your child’s
arousal from sleep.
I.
II.
III.
IV.
V.
VI.
VII.
Awakens with the slightest noise or from turning on the light in the room
Awakens when called by name gently
Awakens when called by name loudly or the sound of bedside alarm clock
Awakens upon shouting the name at the ear or upon gentle shaking
Awakens only with loud noise and vigorous shaking
Awakens when physically stood up
Awakens when walked from the bed to the toilet with support; voids
in toilet while awake
VIII. Doesn’t awaken, has to be carried out of bed/ voids in the toilet without waking
31.
a. Is it difficult or painful for your child to pass stools?
NO
b. Does this child manifest stool leakage/stool straining/skid
marks on his/her underpants?
c. Does this child withhold stools?
d. Were any of the following measures ever used to help
resolve the constipation/stool soiling problem?
1. oral laxative
2. suppositories
3. mineral oil
4. higher fiber diet
5. enemas
6. others:____________________________
MD Signature:___________________
Date:_________________
5
YES
NO
NO
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
Patient Name:______________________
D.O.B.:_______________
PERINATAL HISTORY
32. Was this child born on time?
YES NO
33. How much did this child weigh at birth?
34. Were there any problems with this child during delivery or in the first month of
life?
If yes, explain
NO
YES
_
35. Were there any problems during pregnancy with this child,
pressure, too much or too little amniotic fluid/abnormal
prenatal sonogram?
NO
YES
NO
YES
NO
NO
YES
YES
PAST HISTORY AND GENERAL HEALTH
36. Has this child had any significant or recurring illness?
37. Has your child ever: (circle)
a.
b.
Been hospitalized
Had an operation/ significant injury
38. Has there been any problems with your child’s growth and/ or
development?
NO
YES
39. Do you think that your child’ has any mental and/or
emotional problems?
YES
MD Signature:___________________
NO
Date:_________________
6
Patient Name:______________________
D.O.B.:_______________
40. Has this child had trouble in school?
NO
If yes, please explain
YES
_____
41. Does your child have allergies to food or drugs?
If yes, please explain
NO
YES
_____
42. Is this child’s hearing normal?
YES
NO
43. Did the child receive the recommended immunizations?
YES
NO
FAMILY HISTORY
NAME
AGE
ANY ILLNESS
__________
________________
Father:
Mother: ____________________
Brothers:
Sisters:
44. Father’s employment:
45. Mother’s employment:
MD Signature:___________________
Date:_________________
7
Patient Name:______________________
D.O.B.:_______________
46.
Do any of the following medical conditions run on either side of the family?
a.
b.
c.
d.
e.
Kidney disease
High blood pressure
Protein in urine
Blood in urine
Decreased hearing
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
f.
g.
h.
i.
j.
Urinary infections
Weak bladder
Bedwetting
Kidney stone
Excessive bleeding
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
k.
l.
m.
n.
o.
Irritable bowl syndrome
Constipation
Urinary Tract malformation
Diabetes
Other (specify):
NO
NO
NO
NO
YES
YES
YES
YES
____
47. Is there any other problem not covered in this questionnaire
which you would like to discuss, or any comment that
you would like to make?
_____
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.
MD Signature:___________________
Date:_________________
8