Adult Continence Self-Referral Form
Please return the form to: Continence Promotion Service, Gate House St. Charles Hospital, Exmoor Street,
London, W10 6DZ. Tel 0208 962 4546, Fax 0208 962 4158 or continence.promotionservice@kc-pct.nhs.uk
PATIENT GP
Forename Name
Surname Address
Address Telephone
Telephone Date of Self-Referral
DoB
Where did you Do you have other Yes No
hear about the specific needs? E.g. Please specify:
service? Transport, wheelchair
Gender Male Female access.
Interpreter Language
Required Yes No Ethnicity
PRESENTING SYMPTOMS Yes No Please give details or circle/delete appropriately.
Urgency in needing to pass urine or Urine. Faeces. Both.
faeces?
Need to go far more frequently than
others/before?
Wakening through the night to go to the
toilet or not waking and soiling the bed?
Urge urinary incontinence e.g. leak with urgency
Stress urinary incontinence e.g. leak with cough/laugh/run/sneeze/walk/lifting
Faecal symptoms e.g. leak from the back passage/unable to control wind
Constipation e.g. strain to open bowels/infrequently pass hard stool/give
yourself perineal support/manual evacuation
Difficulty passing urine
Pelvic organ prolapse e.g. vaginal heaviness, the feeling of something coming
down into the vagina, dragging sensation.
Pain on passing urine
Pain on sexual intercourse
Men Only – Post prostectomy
Other
Do you suffer from regular Urinary Tract Infections Yes No
If so when was the last urine sample Result:
given? Date - Antibiotics Prescribed? Yes No
ANY OTHER INFORMATION RELEVANT TO THIS PROBLEM (inc. bladder/bowel investigations / examinations)
Have you received assessment / treatment for this problem before: Yes No
If yes, please specify:
MEDICATION – please list current medication
RELEVANT PAST MEDICAL HISTORY i.e. medical conditions/past surgery/number of children (year born) and type of
delivery/ gynaelogical conditions.
OFFICE USE ONLY Nurse Assessment
Date received: / / Physiotherapy Assessment
Date triaged: / / Education Class – then Nurse / PT Assessment
Triaged by: Inappropriate
Urgent Routine Other