Client Information Form

In order for us to advise you on the best course of action, we need some information about your child's history.  Please fill in the form below.  We will treat all information with complete confidentiality.  If you wish to order a Dri-Sleeper alarm, we will still need the information, to ensure that your child is a suitable candidate for the programme, and does not need further medical checks first.  If s/he is suitable, we will contact you to arrange payment details.

Send me a Dri-Sleeper alarm

Have a support person contact me

 My child has been a bedwetter since s/he was a baby: 

  Yes        No  

  My child was dry for 6 months or longer at one time   

  Yes          No  

 If yes to above question, at what age did s/he start wetting again?

Has your child experienced any stressors or trauma that you know of?  Give details.

 No. of nights per week wet  

No of wets per night          

Wears nappies at night:  Yes     No 

I take him/her to the toilet during the night 

 Yes    No 

 Daytime continence:  Yes    No    

If No, describe the pattern of daytime wetting

 Daytime urination:  frequent     infrequent     average 

Any difficulties with urinary flow ( dribbling, spraying, difficulty in starting, pain)

 Faecal soiling            yes      no        

 History of Urinary Tract Infections:    no       one       more than one       no, but never tested   

 Previous Investigations:  

    Previous treatments for bedwetting and success of these: 

    Child's attitude to the bedwetting:  

    Family's attitudes to the bedwetting: 

    Medical Aid      yes          no  

    If yes, Medical Aid Name: