Bristol Community Health Bladder and Bowel Service Assessment Form Admission Date: Client registered as (please tick): Residential Date of Assessment: Nursing Patient’s Name: Date of Birth: NHS Number: Male/ Female Address (Please include Unit or Floor): GP Surgery Post Code: Post Code Telephone Number: GP Telephone Number All please complete section 1- 8 1. Presenting Bladder / Bowel Problem Action Urinary Yes No If referrals made to Urology/ Gastroendology etc. include letters and Faecal Yes No investigations. Nocturia/ Nocturnal Yes No Polyuria If bladder problems complete a 4 day bladder diary and symptom profile Date of of problem Who else have they consulted re this problem: Name number…………………………………. Date of Birth…………… ……………………….NHS 3. Patient’s and/or Carer’s Aims and Goals for If pads required please state type & size. Include hip & waist measurements Treatment to ensure correct fitting product.
Bristol Community Health Bladder and Bowel Service Assessment Form Client registered as (please tick): Residential Nursing Admission Date: Date of Assessment: Patient’s Name: Date of Birth: NHS Number: Male/ Female Address (Please include Unit or Floor): GP Surgery Post Code: Post Code Telephone Number: GP Telephone Number All please complete section 1- 8 1. Presenting Bladder / Bowel Problem Action Urinary Yes No If referrals made to Urology/ Gastroendology etc. include letters and investigations. If bladder problems complete a 4 day bladder diary and symptom profile Faecal Yes No Nocturia/ Nocturnal Polyuria Yes No Date of of problem Who else have they consulted re this problem: Name ……………………….NHS number…………………………………. Date of Birth…………… 3. Patient’s and/or Carer’s Aims and Goals for Treatment If pads required please state type & size. Include hip & waist measurements to ensure correct fitting product.