Any specific requirements or needs? Yes No If yes please specify Clinical Findings Urinalysis results normal Yes MSU result (if dipstix abnormal) No Abdominal Examination State findings Normal Abnormal BMI BP Comments Male Female Family History of Prostate Cancer? Vaginal Examination State findings If yes please provide details Yes No Yes Any Symptoms of Vaginal Prolapse? No Yes No State findings Findings of DRE if performed: Obstetric Number of Number of Instrumental History pregnancies Births Deliveries Patient Opted Out of PSA investigation Caesarean Sections Given Birth in the last year Yes Yes No No Blood Creatinine um/1 PSA Ng/ml Symptom Profile Adult please tick relevant boxes – I leak when I laugh, cough, sneeze, run or jump I only ever leak a little At night, I only use the toilet once or not at all I always know when I have leaked I leak without feeling the need to empty my bladder ESS Only my pants get wet when I leak I leak urine during sexual intercourse STR I feel sudden urge to pass urine and have to go quickly I feel a strong uncontrolled need to pass urine prior to leaking I leak moderate amounts before I reach the toilet I feel that I pass urine frequently I get up at night to pass urine at least twice URGE I think I had bladder problems as a child I find it hard to pass urine I have to push or strain to pass urine My urine flow stops and starts several times My urine stream is weaker than it used to be I feel that it takes me a long time to empty my bladder I feel as if my bladder is not completely empty after I have been to the toilet I leak a few drops of urine on my underwear just after I have passed urine OVERFLOW 0-4 How many times a day do you pass urine? 4-7 8+
Any specific requirements or needs? Yes No If yes please specify Clinical Findings Urinalysis results normal Yes No MSU result (if dipstix abnormal) Abdominal Examination State findings Normal Abnormal BMI BP Comments Male Female Family History of Prostate Cancer? If yes please provide details Yes No Vaginal Examination State findings Yes No Any Symptoms of Vaginal Prolapse? Yes No State findings Findings of DRE if performed: Obstetric History Number of pregnancies Number of Births Instrumental Deliveries Patient Opted Out of PSA investigation Yes No Caesarean Sections Given Birth in the last year Yes No Blood Creatinine um/1 PSA Ng/ml Symptom Profile Adult – please tick relevant boxes STR ESS I leak when I laugh, cough, sneeze, run or jump I only ever leak a little At night, I only use the toilet once or not at all I always know when I have leaked I leak without feeling the need to empty my bladder Only my pants get wet when I leak I leak urine during sexual intercourse URGE I feel sudden urge to pass urine and have to go quickly I feel a strong uncontrolled need to pass urine prior to leaking I leak moderate amounts before I reach the toilet I feel that I pass urine frequently I get up at night to pass urine at least twice I think I had bladder problems as a child OVERFLOW I find it hard to pass urine I have to push or strain to pass urine My urine flow stops and starts several times My urine stream is weaker than it used to be I feel that it takes me a long time to empty my bladder I feel as if my bladder is not completely empty after I have been to the toilet I leak a few drops of urine on my underwear just after I have passed urine How many times a day do you pass urine? 0-4 4-7 8+
Warrington-Bladder-and-Bowel-Care-Service-referral-form.docx