Treating the deep sleep that causes bed wetting

Patient Information Form

Thank you in advance for completing this form.  This information is essential because it allows us to learn more about the patient, and to develop a suitable treatment process.  Your information will be kept strictly confidential.  If a question is not relevant, please enter “NA”.   Please take a few minutes now to complete and then click submit.  

Patient Full Name

Name preferred to be called

Birthday

Age

Patient's Height

Patient's Weight

Average Wetting Episodes Per Week

Any family members who presently wet the bed, including extended family

Ever diagnosed with diabetes, hypoglycemia or seizures? If yes, please list.

Any medical condition(s) requiring medications? List medications.

Referred by a Pediatrician?
YesNo

School attending
CharterHomePrivatePublic

School grade/level

School grades/marks

Reading level (above, at or below)

Mother's Full Name

Father's Full Name

Telephone Number

Address 1

Address 2

City

State

Zip

Country

Email

Mother's Occupation

Father's Occupation

Father's Employer

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