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Locations
Leigh Health Centre
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The Cobbles, Meltham Surgery
The Grange Group Practice
Todmorden Health Centre
Waterloo Practice
Windhill Green Medical Practice
Young Batley Centre
Children's Continence SOUTH ONLY
Referral criteria
Child much be registered with a Kirklees GP
Refer bed wetting and day wetting to Huddersfield Royal by calling 01483 343477
Refer for toilet training and products age 4 years
Refer for constipation from age 2 years
Child's details
If contact details are incorrectly input where mandatory the referral cannot be processed
Child's name *
Parent/carer's name *
DOB *
Sex *
Please select
Male
Female
NHS no *
Religion
Child's current address *
Postcode *
Tel no *
Email address *
Skype ID
Ethnicity
Next of kin
Overseas visitor?
Yes
No
GP name *
Consultant
Please state all the languages spoken at home: *
Is an interpreter needed for child/carer/parent? *
Yes
No
If Yes, for what language?
Are there any communication needs for this child or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *
Yes
No
What might be helpful when communicating with this child or their parent/carer?
Consent for contact by email *
Yes
No
Referral discussed with parents *
Yes
No
Do parents consent to referral? *
Yes
No
Patient consented to information sharing? *
Yes
No
Name of school/nursery
EHC plan or statement
Yes
No
Diagnosis/Medical History/Medications/Allergies
Referrer name *
Referrer email *
Referrer contact details *
Referrer job title *
Referring from
Please select
Acute
Care Home
GP Practice
Hospice
Local Authority
School
Self Referral
Optional Attachment
(Optional) - Please attach any clinical letters/any other relevant information
Upload file
Continence Details
Main continence problem
Daytime wetting
Enuresis
Toilet Training
Encopresis
Constipation
Any Family History of continence (siblings / parents)
When did the problem start?
Interventions tried
Has the child ever been dry? (DAY)
Yes
No
Has the child ever been dry? (NIGHT)
Yes
No
Has the child ever been clean? (DAY) (Not Soiling)
Yes
No
Has the child ever been clean? (NIGHT) (Not Soiling)
Yes
No
Has toilet training been tried/in progress?
Yes
No
Does the child wet the bed?
Yes
No
Do they have recurrent urine infections?
Yes
No
Any previous investigations on bladder or bowel?
Yes
No
Urinalysis
Yes
No
Diet (A typical day)
Breakfast
Dinner
Tea
Supper
Detail
Fluids - Type and Amount
Frequency of voids/wetting?
Frequency of any soiling?
Does the child experience any pain on bowel movement?
Yes
No
Does the child ask to go to the toilet for a wee or poo?
Yes
No
Where does the child normally open their bowels?
Toilet fears
Yes
no
Any continence products used recently?
Parent's perception of continence problem?
Child's perception of continence problem?
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