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Pre-Consultation Form

Thank you for providing Dr. Hodges with background about your child’s toileting difficulties. 

 

Please fill out a separate form for each child. 

 

Once we have received your form, along with your payment via PayPal, your time zone, and your preference for FaceTime, Zoom, Skype, or phone, we will contact you to schedule the consultation. Please hang on to any x-rays until after we have confirmed a time slot. At that point, you can email your images to Dr. Hodges at shodges@wakehealth.edu.  

*Please note: This form cannot be saved online. You may want to scroll through or print it before filling it out so that you have the information on hand.

Contact Information

*Optional

List any medical professionals who have treated your child for toileting difficulties. During the consultation you can let Dr. Hodges know whether you’d like him to consult with your physician.

TOILETING TROUBLES

Please select any that apply:

Bedwetting (nocturnal enuresis)
Daytime pee accidents (enuresis)
Poop accidents (encopresis)
Urinary frequency/urgency
Recurrent urinary tract infections (UTIs)

Summary

TREATMENTS

TOILET TRAINING HISTORY

Did/does your child have difficulty toilet training?

IMAGING STUDIES

Has your child had an abdominal X-ray, kidney/bladder ultrasound, or any other imaging studies?

MEDICATIONS

Is your child currently taking any prescription or over-the-counter medications (including MiraLAX)?

MEDICAL HISTORY

Please indicate whether your child has now or has ever been diagnosed with any medical conditions, including the following:

Apnea
Autism
Asthma or bronchitis
Congenital abnormalities
Developmental delays
Diabetes, thyroid disorders, or adrenal disorders
Hepatitis or liver disease
Kidney disease
Heart disease
Musculoskeletal conditions (hypotonia, muscle disease, fractures)
Neurologic disorders (hydrocephalus myelodysplasia, myopathy)

ADDITIONAL INFORMATION

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