Name Date SECTION A: Continence Care Goals and Preferences. BLADDER PROBLEMS. 1. Is the person currently experiencing a bladder problem? YesNoIf ‘yes’, what is the nature of the problem? 2. Does the person have a history of a bladder problem? YesNoIf ‘yes’, what is the nature of the problem? 3. If ‘bladder problems’, what kind of support would they prefer? IndependantTo be assisted to go to the toilet (specify preferred toileting times)To wear an incontinence pad/aid during the dayTo wear an incontinence pad/aid during the nightTo be seen by a specialist for further investigationOther 4. Is the person currently experiencing a bowel problem? YesNoIf ‘yes’, what is the nature of the problem? 5. Does the person have a history of a bowel problem? YesNoIf ‘yes’, how does it affect them? 6. If ‘bowel problems’, what kind of support would they prefer? IndependantTo be assisted to go to the toilet (specify preferred toileting times)To wear an incontinence pad/aid during the dayTo wear an incontinence pad/aid during the nightTo have a regular aperientTo be seen by a specialist for further investigationOther SECTION B: Usual Management. 7. Does the person use or wear a product to help maintain their social incontinence? YesNoA urinal?A bedpan?Condom Drainage?A commode?An incontinence pad/aid?If ‘yes’, which brand & size, numbers per day, numbers per night? 8. Does the person use an incontinence product to assist with their toileting? YesNoA urinal?A bedpan?Other Your contact phone number *EmailSubmit
