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.
 I take these prescription medicines:
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________
medicine: ________________________ dose: _________________
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
within the past few months
1 to 2 years ago
________ years ago
Number of babies I have had:_____________________
Dates:_________________________________________
My periods stopped—menopause.
Date:__________________________________________
I 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 smoke cigarettes.
I have pain or a burning feeling when I urinate.
I often have a really strong urge to urinate right away.
Sometimes my bladder feels full, even after I finish urinating.
I go to the bathroom often, but very little urine comes out.
I don’t go out with friends or family because I worry about leaking urine.
The first thing I do at new places is check the bathroom location.
I worry about being put in a nursing home because of bladder control problems.
I have, or had, these medical problems:
| cancer |
depression |
| crippling arthritis |
diverticulitis |
| diabetes |
multiple sclerosis |
| interstitial cystitis |
stroke |
| spinal cord injury |
other_____________________ |
| 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.
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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