apples walking checkup

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What Your Doctor Needs to Know

To prepare for your doctor's appointment, check all the boxes below that apply to you. This information will help your doctor understand your bladder control problem.

checkbox  I take these prescription medicines:
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________

checkbox  I take these over-the-counter drugs (such as Tylenol, aspirin, or Maalox):
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________

If you take more medicines, please list them on a separate paper.

I started having bladder trouble

checkbox  within the past few months
checkbox  1 to 2 years ago
checkbox  ________ years ago

checkbox  Number of babies I have had:_____________________
Dates:_________________________________________

checkbox  My periods stopped-menopause.
Date:__________________________________________

checkbox  I had an operation.
Date:__________________________________________
Type of operation:________________________________

checkbox  I recently hurt myself or have been sick.
Date: _________________________________________
Type of injury or illness:____________________________

checkbox  I recently had a bladder—urinary tract—infection.
Date: _________________________________________

checkbox  I smoke cigarettes.

checkbox  I have pain or a burning feeling when I urinate.

checkbox  I often have a really strong urge to urinate right away.

checkbox  Sometimes my bladder feels full, even after I finish urinating.

checkbox  I go to the bathroom often, but very little urine comes out.

checkbox  I don't go out with friends or family because I worry about leaking urine.

checkbox  The first thing I do at new places is check the bathroom location.

checkbox  I worry about being put in a nursing home because of bladder control problems.

I have, or had, these medical problems:

checkbox  cancer checkbox  depression
checkbox  crippling arthritis check  diverticulitis
checkbox  diabetes checkbox  multiple sclerosis
checkbox  interstitial cystitis checkbox  stroke
checkbox  spinal cord injury checkbox  other_____________________
checkbox  urinary infection  

National Kidney and Urologic Diseases Information Clearinghouse

3 Information Way
Bethesda, MD 20892-3580
Phone: 1-800-891-5390
TTY: 1-866-569-1162
Fax: 703-738-4929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov

The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about kidney and urologic diseases.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1–888–INFO–FDA (1–888–463–6332) or visit www.fda.gov. Consult your health care provider for more information.


NIH Publication No. 07–4195
August 2007

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Page last updated April 2, 2014


 

The National Kidney and Urologic Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: nkudic@info.niddk.nih.gov
Internet: www.kidney.niddk.nih.gov

Department of Health and Human Services The National Institute of Diabetes and Digestive and Kidney Diseases USA.gov is the U.S. government's official web portal to all federal, state, and local government web resources and services. This website is certified by Health On the Net Foundation. Click to verify.

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