Date of birth | ||||
---|---|---|---|---|
Current history | Symptoms | |||
Redness | Y/N | |||
Soreness | Y/N | |||
Itching | Y/N | |||
Discharge | Y/N | |||
Bleeding | Y/N | |||
Duration of symptoms, previous episodes | ||||
Past history | ||||
UTI | Y/N | |||
Eneuresis | Y/N | |||
Constipation | Y/N | |||
Encopresis | Y/N | |||
Skin disorder | Y/N | |||
Other illness in last 4 weeks | Y/N | |||
Antibiotic use in last 4 weeks | Y/N | |||
Toileting | Toilet trained | Y/N | ||
Wipe front to back | Y/N | |||
Need assistance with wiping | Y/N | |||
Hygiene | Frequency of bathing (daily, 2–4 times/week, once weekly or less) | |||
Underwear (cotton, synthetic, both) | ||||
Bubble bath in last month | Y/N | |||
Possible sexual abuse |
UTI, urinary tract infection.