Preliminary Diagnostic Questionnaire

The information you provide in this questionnaire will enable our professional staff to help you in identifying the diagnostic group your child should be related to. In case you need help on this matter please respond to the questions and we will come back to you with our impression.

Name

Age

Sex

Female Male

Wets during sleep:

Wets During the day:

Uses the toilet for urinating

Uses the toilet for defecating:

Asks for a diaper to Poo:

Poos in the pants:

Makes a full bowel movement in the diaper or in the pants once or twice a day

Yes No

Releases small quantities of feces several times a day in the pants or in the diaper:

Yes No

Constipates and withholds for several days

Has used the toilet or a potty for a significant period in the past:

Short history and description of the problem:

1. Your specific question:

2. Your specific question: