Bladder Health
What does the doctor need to know?
You will need to keep a record. Try to write down the times when you go to the bathroom. Write down when you have accidents, too. Do this for a day or more. This record is called a bladder control diary. Diaries help your doctor or nurse learn the cause of your problem.
What Your Doctor Needs to Know
I take these prescription medicines:
_______________________________________________
_______________________________________________
_______________________________________________
I take these over-the-counter drugs (such as Tylenol, aspirin, or Maalox):
_______________________________________________
_______________________________________________
_______________________________________________
If you take more medicines, please list them on a separate paper.
I started having bladder trouble:
___ recently
___1 to 2 years ago
___ years ago
Number of babies I have had:________
Dates:_________________________________________
My periods stopped (menopause).
Date:__________________________________________
I recently had an operation.
Date:__________________________________________
Type of operation:________________________________
I recently hurt myself or have been sick.
Date: __________________________________________
Type of injury or illness:____________________________
I recently had a bladder (urinary tract) infection.
Date: _________________________________________
I am often constipated. __yes __no
I have pain or burning feelings when going to the toilet.
__yes __no
I often have a strong urge to go to the toilet right away.
__yes __no
My bladder feels full, even after I go to the toilet. __yes __no
I go to the toilet often, but very little urine comes out. __yes __no
I don't go out socially because I worry about leaking urine.
__yes __no
The first thing I do at new places is check the bathroom location.
__yes __no
I worry about being put in a nursing home because of bladder control problems.
__yes __no
I have (or had) these medical problems:
__Cancer
__Constipation
__Crippling arthritis
__Diabetes
__Depression
__Diverticulitis
__Interstitial cystitis
__Multiple sclerosis
__Spinal cord injury
__Stroke
__Urinary infection
__I smoke cigarettes.
Information provided by:
National Institute for Diabetes, Digestive and Kidney Disease
