Interview questionnaire
| 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.