Genitourinary History

Yes / No

Number of times that you urinate at night? 
0
Number of times that you urinate during the day? 
5-6
Any trouble starting the urine stream? 
N
Any trouble stopping the urine stream? 
N
Any pain with urination? 
N
Any difficulty holding urine? 
N
Any back pain related to urination? 
N
Ever had blood in urine? 
N
Ever had puffiness of face or eyes? 
N
Number of pregnancies Age(s) of child (children).
2; (10, and 14)
Number of miscarriages
None
Number of abortions
None
 
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©1998,  Neal R. Chamberlain, Ph.D.. All rights reserved.