Patient Information Form (child) - Bedwetting Treatment Center

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Bedwetting Treatment
Help For…
- Teens
- Children
- Parents
Resources
About Us
- Our Legacy
- Our Directors & Therapists

800-379-2331

Patient Information Form

Please complete this form.

Patient's Name(Required)

First Last

Gender:(Required)

Male

Female

Name Patient Prefers to Be Called:

Birthdate:(Required)

MM slash DD slash YYYY

Age:(Required)

Height:(Required)

Weight:(Required)

Average Wetting Episodes Per Week:(Required)

Has patient been diagnosed with diabetes, hypoglycemia, or seizures? If yes, please list.(Required)

Any medical condition(s) requiring medications? If yes, please list.(Required)

Type of School Attending - Choose One:(Required)

School Grade:(Required)

Grade Average:(Required)

Reading Level (above, at, or below):(Required)

Mother's Name:(Required)

First Last

Father's Name:(Required)

First Last

Phone number to be called at the time of consultation:(Required)

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email Address:(Required)

Mother's Occupation:(Required)

Mother's Employer:(Required)

Father's Occupation:(Required)

Father's Employer:(Required)

Any additional family members who live with bedwetting? If so, please list relationship to patient.

Were You Referred by a Pediatrician?

Yes

No

Were You Referred by a Friend?

Yes

No

If Yes, Whom Shall We Thank?

If Not Referred, How Did You Find Us?

Google

Facebook

YouTube

Other

Search

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