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Urinary Incontinence

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Patient Information

Full Name *

Age *

Gender *

State the type of urinary incontinence

Specify the type of urinary incontinence

Leakage with coughing, sneezing, laughing

Sudden urgency and leakage before reaching the toilet

Both types are present

What type of kidnapping is

Predominant type of incontinence

Stress incontinence is more frequent than urge incontinence

Urge incontinence is more frequent than stress incontinence

Burning, bleeding in urination

Burning or bleeding during urination

Burning during urination

Blood in urine

Difficulty urinating

When did your first complaint start?

When did your symptoms start?

Please inform us about the history of your illness:

Urinary frequency and frequency of urinary incontinence

Daytime urination count (from waking up to going to bed)

Number of times waking up at night to urinate (include the first morning urination)

How many times per day does incontinence occur?

Extent of urinary incontinence

Do you use a protective pad for incontinence?

How many pads (newborn diaper size) are wet per day?

Disease History

Your additional diseases:

Do you have a history of stroke, accidents, herniated disc operations, spinal cord surgeries, or brain hemorrhage?

Previous surgeries (if any):

Please state the medications you take on a regular basis (with doses)

Do you have a first or second degree relative with urinary incontinence?

If yes, please indicate:

Have you received any previous treatment for this disease?

Have you previously received treatment for this disease?

Fluid restriction, constipation treatment

Pelvic floor muscle exercises (rehabilitation)

Medication treatment

Surgery

Treatment Start Date

Treatment End Date

Treatments You Received

Treatment Start Date

Treatment End Date

Treatments You Received

Treatment Start Date

Treatment End Date

Treatments You Received

Treatment Start Date

Treatment End Date

Treatments You Received

Imaging (Radiology) Reports

Urinary Tract Ultrasonography

Laboratory Examinations

Complete urinalysis report

Urodynamics result

Hemogram (Complete Blood Count) Report

Biochemistry Report

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