©1999, Herbert A. Yates, D.O. and Neal R. Chamberlain, Ph.D.. All rights reserved.
| Number of times that you urinate at night? |
|
| Number of times that you urinate during the day? |
|
| Any trouble starting the urine stream? |
|
| Any trouble stopping the urine stream? |
|
| Any pain with urination? |
|
| Any difficulty holding urine? |
|
| Any back pain related to urination? |
|
| Ever had blood in urine? |
|
| Ever had puffiness of face or eyes? |
|
| Number of pregnancies. Age(s) of child (children). |
|
| Number of miscarriages |
|
| Number of abortions |
|
©1999, Herbert A. Yates, D.O. and Neal R. Chamberlain, Ph.D.. All rights reserved.