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Home : Kidney & Urologic Diseases A-Z List of Topics and Titles : Bladder Control for Women : What I need to know about Bladder Control for Women
 
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National Kidney and Urologic Diseases Information Clearinghouse

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.

This is an image of a check box.  I take these prescription medicines:
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________

This is an image of a check box.  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

This is an image of a check box.  within the past few months
This is an image of a check box.  1 to 2 years ago
This is an image of a check box.  ________ years ago

This is an image of a check box.  Number of babies I have had:_____________________
Dates:_________________________________________

This is an image of a check box.  My periods stopped—menopause.
Date:__________________________________________

This is an image of a check box.  I had an operation.
Date:__________________________________________
Type of operation:________________________________

This is an image of a check box.  I recently hurt myself or have been sick.
Date: _________________________________________
Type of injury or illness:____________________________

This is an image of a check box.  I recently had a bladder—urinary tract—infection.
Date: _________________________________________

This is an image of a check box.  I smoke cigarettes.

This is an image of a check box.  I have pain or a burning feeling when I urinate.

This is an image of a check box.  I often have a really strong urge to urinate right away.

This is an image of a check box.  Sometimes my bladder feels full, even after I finish urinating.

This is an image of a check box.  I go to the bathroom often, but very little urine comes out.

This is an image of a check box.  I don’t go out with friends or family because I worry about leaking urine.

This is an image of a check box.  The first thing I do at new places is check the bathroom location.

This is an image of a check box.  I worry about being put in a nursing home because of bladder control problems.

I have, or had, these medical problems:

This is an image of a check box.  cancer This is an image of a check box.  depression
This is an image of a check box.  crippling arthritis This is an image of a check box.  diverticulitis
This is an image of a check box.  diabetes This is an image of a check box.  multiple sclerosis
This is an image of a check box.  interstitial cystitis This is an image of a check box.  stroke
This is an image of a check box.  spinal cord injury This is an image of a check box.  other_____________________
This is an image of a check box.  urinary infection  

National Kidney and Urologic Diseases Information Clearinghouse

3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
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.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.

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

NIH Publication No. 07–4195
August 2007

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The NKUDIC 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
Fax: 703–738–4929
Email: nkudic@info.niddk.nih.gov
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