Children's Continence SOUTH ONLY

Refer for continence products if child is 4 years of age.

Refer child if they have COMBINED faecal soiling/constipation AND day/night enuresis.

If child has ONLY day/night wetting refer to Community Paediatrics at Huddersfield Royal 01484 342000

Children's Continence

Child's details
If contact details are incorrectly input where mandatory the referral cannot be processed
Overseas visitor?
Consent for contact by email:*
Referral discussed with parents:*
Do parents consent to referral?*
Patient consented to information sharing?*
Please tick to confirm that the parent/carer consents to their child receiving assessments and interventions, as is appropriate to this referral:*
The parent/carer should be aware that if at any point they do not want further treatment or interventions, they must inform their clinician:*
EHC plan or statement:
Optional Attachment
Continence Details
Main continence problem:
Has the child ever been dry? (DAY)
Has the child ever been dry? (NIGHT)
Has the child ever been clean? (DAY) (Not Soiling)
Has the child ever been clean? (NIGHT) (Not Soiling)
Has toilet training been tried/in progress?
Does the child wet the bed?
Do they have recurrent urine infections?
Any previous investigations on bladder or bowel?
Urinalysis
Diet (A typical day)
Detail
Does the child experience any pain on bowel movement?
Does the child ask to go to the toilet for a wee or poo?
Toilet fears
If you do not receive an email acknowledgement your referral has not been submitted. Please check that all details are correct, mandatory fields completed and re-submit.