Patient Name ………………………………. NHS Number …………… Date of Birth…………..
Please use this form together with your standard referral letter, which will contain practice details, patient demographics, relevant medical history and medications. For reference purposes, please can you also complete the patient name and NHS number in the header above.
NB : Patients with haematuria should be referred to the Urology Rapid Access Clinic
1. The continence promotion service is for patients with symptoms of bladder and/or bowel dysfunction and/or incontinence. Please indicate and give details below of presenting symptoms:
Symptoms of a voiding difficulty & weak stream / / Continuous urinary leakage / / Bladder pain
Pain on passing urine /
Symptoms of incomplete emptying / / Prolapse symptoms/signs with lower urinary tract symptoms /
/ Neurological signs with lower urinary tract symptoms /
Recurrent, proven lower urinary tract infections / / Failed conservative management / / Abnormal examination, e.g. mass/fistula/palpable bladder /
Symptoms of urgency to pass urine or
faeces or
both / / Reduced fixed volumes on urinary diary
Need to pass urine more frequently than two hourly / / Leaks urine with activity eg: cough,laugh,sneeze, run, lifting.
Bowel symptoms eg: chronic constipation /
Other Relevant details:
Yes No
Is the urinalysis/MSSU normal?
Has their fluid intake been reviewed?
Have significant bowel problems been excluded?
Has current medication been reviewed?
Has significant cognitive impairment been identified?
Has any atrophic vaginitis been treated with 2/12 of topical oestrogens?
Has a urinary diary been completed?
This form can be used for referral to the Gloucestershire Continence Promotion Service on Fax No. 08454 225311 or email
If conservative management is unsuccessful, these services can refer the patient onwards.
3. Please indicate any other relevant history:
Number of pregnancies cystoscopy TURP back problems constipation dementia
Difficult deliveries
Hysterectomy Depression Diabetes Learning Difficulties Parkinson’s MS
Pelvic/ continence surgery Mental health issues Other
4. Relevant current medication please list:
5. Other significant information:
BMI: Weight: BP:
Gloucestershire Continence Promotion Service referral form 21.07