Symptom Summary Form

Submit the Symptom Summary

I have read the terms and conditions *
General information about your lifestyle
Some specific questions about your symptoms
2. What statements best describe your bladder symptoms
If you do wear pads are they
And how many pads do you use each day
4. Many women find their symptoms affect their sex life
5. Some women remember having bladder problems in their childhood
7. How do your symptoms affect your daily life *
on a scale of 0 to 10 where 0 is 'not at all' and 10 is 'a great deal'
Your overall health
Diabetes *
Underactive or overactive thyroid *
Recurrent urine infections *
Cystitis *
Multiple Sclerosis , Parkinson’s or other neurological condition *
Stroke *
Glaucoma *
Severe back or neck problems *
Spinal Injury *
1. Do you smoke *
2. Have you had any surgery around your lower abdominal area eg hysterectomy or bladder repair *
What surgery did you have and when was this surgery?
3. Have you had any tests at the hospital on your bladder or bowel *
What investigations did you have? When were the investigations performed? What was the outcome of the investigations
4. Do you take any regular medications *
pregnancies
Periods
Please tick all relevant answers
I have had cancer in my pelvic region *
Specific questions about your bowels
1. Your bowel habit
I have noticed blood in my stool *
I have noticed a lasting change in my bowel habit (ie the number of times you go to the toilet or the consistency of your stool) *
I am losing weight *
I have abdominal pain or pain in my back passage *
4. Constipation is a very common problem
please tick all relevant answers