Patient Details

Title *

First Name *

Preferred Name

Last Name *

Gender *

MaleFemaleNon-binaryDifferent identity

Pronouns:

He/Him/HisShe/Her/HersThey/Them/TheirsOther

Date of Birth *

Email Address *

Home Phone

Mobile *

Work Phone

Address Line 1: *

Address Line 2:

Suburb: *

State: *

Post Code: *

Communication with our patients is our priority. Please mark your preferences: *

SMSEmailCommunication of upcoming appointmentsCommunication regarding special offers, conditions, treatments & general clinic announcements (our aim is to send relevant and important information to you)

Emergency Contact

Next of Kin

Relationship

Contact Number/s

GP Information

GP Name

Clinic

Referrer Information (if different from GP information)

Please tell us who to thank for referring you to our clinic

(if different from above GP details)

Referrer Name

Referrer Clinic

Please list other allied health or medical professionals currently involved in your child's care

COVID-19

Please take note of COVID-19 protocols we have put in place:

We have implamented a COVID safe clinic by following WA Health guidlines
Patients and staff are required to wear a mask in our clinics
Our clinics are sanitise regularly and we kindly ask patients to practice good personal hygiene

Privacy Statement

Your personal health information and your Records may be collected, used and disclosed, including but not limited to, the following reasons:

For communicating relevant information with treating doctors, specialists, insurers or other alied health professionals
For use by all physiotherapists in this group practice, when consulting you
For research purposes (de-indentified, meaning you are not able to be indentified from information given

If you have any concerns or wish to restrict access to your personal health information, please discuss these with your treating physiotherapist.

ALL PATIENT PLEASE READ AND SIGN

DECLARATION: I understand and agree that:

If I am unable to attend my appointment I will give 24 hours notice of my cancellation. If I do not cancel with notice I will be charged a Non-Attendance Fee for my missed appointment.
I am required to pay on the day for all consultations. Body Logic Physiotherapy accepts, cash, cheques and has EFTPOS and HiCaps facilities. If my account is not paid at the time of consultation, administration feed maybe added.
In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred.
For insurance claims, I will be personally responsible for payment of all accounts incurred by me in the event that liability is denied, or placed in dispute by the insurance company.
I consent to treatment provided by the physiotherapist.

Any comments in regards to your appointment:

Documents relating to your appointment:

Browse

Is your child participating in NDIS? If YES, please give details.

Signature: *

Draw signature|Type signatureClear

Date: *

Enuresis / Urinary Incontinence (Beetz, Von Gontard, Lettgen, 1994; translated and adapted by A.Von Gontard, 2003)

Daytime Wetting:

If some of these questions is not relevant, please leave unanswered and leave a comment at the end of the form

1. Does your child wet his / her clothes during the day?

2. Has your child ever been dry during the day?

3. If yes, for how long? And at which age?

4. On how many days a week does your child wet during day time?

5. How many times a day does your child wet?

6. Is the clothing usually damp?

7. Is the clothing usually wet?

8. Does urine dribble constantly?

9. Does your child wet his / her clothes immediately after having gone to the toilet?

10. Does your child notice when he / she wets?

Nighttime Wetting:

1. Does your child wet the bed (or diapers) during the night?

2. Has your child ever been dry during the night?

3. If yes, for how long? And at which age?

4. On how many nights a week does your child wet

5. Is the bed usually damp?

6. Is the bed usually wet?

7. Does your child wake up to go to the toilet?

8. Does your child wake up after wetting the bed?

9. Is your child a deep sleeper, i.e difficult to wake up?

10. Has any other member of your family wetted (day or night)?

11. If yes, who?

Toilet Habits:

1. How many times a day does your child void?

2. How long can your child manage without going to the toilet (during shopping, car trips etc)?

3. Does your child go to the toilet him/herself if he / she needs to?

4. Do you have to send your child to the toilet?

5. If your child wants to pee, does he / she have to strain at the beginning or during voiding?

6. When your child voids, if the stream interrupted?

7. Does your child hurry and not take enough time for voiding?

Observable Reactions:

1. Does your child feel a sudden urge to go to the toilet?

2. When your child needs to void, does he / she have to rush to the toilet immediately?

3. Does your child cross his / her legs, squat, sit on a heel etc to prevent wetting?

4. Does your child postpone going to the toilet as long as possible?

5. If yes, in which situations (school, play, TV etc), please specify:

Urinary Tract Infections:

1. Has your child ever had a urinary tract infection?

2. If yes, how many?

3. Has your child had urinary tract infections with fever?

4. Has your child been treated for an illness of the urinary tract?

5. If yes, please specify:

Stool Habits:

1. Does your child have daily bowel movements?

2. If not, how many times per week?

3. Is your child regularly constipated?

4. Does your child soil his / her underwear (during the day)?

5. Does your child soil during sleep?

6. If yes, small amounts (smear)? OR large amounts (stools)?

7. How often does your child soil?

8. Has your child previously had a complete bowel control?

9. If yes, at what age (years). And for how long for (months/years)?

10. Does the soiling occur in special situations?

11. If yes, please specify:

Behaviour: Wetting

1. Is your child distressed by the wetting?

2. Are you distressed because of your child’s wetting?

3. Has your child been teased because of the wetting?

4. Are there any things your child did not do (school outings, sleeping over with friends) because of the wetting?

5. Does your child wet more often in stressful times?

6. Is your child cooperative and motivated for treatment?

7. If your child had been dry before, do you see any event that might be associated with the relapse?

8. If yes, please specify:

9. What in your opinion is the reason for the wetting? Please specify:

Behaviour: General

1. Does your child have difficulties in accepting rules?

2. Is your child restless, on the go, easily distracted?

3. Does your child have difficulty concentrating?

4. Is your child sometimes anxious?

5. Is your child sometimes sad, unhappy, withdrawn?

6. Does your child have problems in school?

7. If yes, please specify:

8. Does your child have problems in other areas?

9. If yes, please specify:

Any comments regarding your child's case/appointment?

Thank you for answering our questionnaire, we greatly appreciate your time and patience!