NIGHT TIME WETTING (NOCTURNAL ENURESIS / BEDWETTING) SERVICE REFERRAL FORM

Referrals will be accepted from GPs, Paediatricians, or clinicians on their behalf, for example, Nurse Practitioners or School Nurses.

This form is designed to be completed and sent electronically via secure email. Each section will expand as you add text.

Please complete all sections, providing as much information as possible to support your referral.

Patient Details
Surname: / First Name: / DOB:
Address:
Email address: / Contact No:
NHS No: / Gender: / Choose an item. /
School: / Ethnicity
GP:
Interpreter required? Choose an item. If yes, please specify language:
Referral Information
Is the Night Time Wetting (Nocturnal Enuresis / Bedwetting) primary (i.e. never dry) or secondary in nature? / Choose an item. /
Is there a family history of Night Time Wetting (Nocturnal Enuresis / Bedwetting)? / Choose an item. /
Are there any of the following features:
  1. Continuous dribbling
/ Choose an item. /
  1. Poor urinary stream in male
/ Choose an item. /
  1. Dysuria
/ Choose an item. /
  1. Backache
/ Choose an item. /
  1. Excessive thirst (waking at night to drink)
/ Choose an item. /
  1. Recent onset of polyuria
/ Choose an item. /
  1. Unexplained fevers
/ Choose an item. /
NB: If the child has any of these symptoms it is advised that they are referred to a Consultant Paediatrician for review before they can be referred to the Night Time Wetting (Nocturnal Enuresis / Bedwetting)Service
Has this child already been reviewed and/or treated by a consultant? / Choose an item. /
Allergies? Choose an item. If yes, please describe:
Is there any previous or current history of constipation? Choose an item. If yes, please detail history & treatment
Are there associated significant emotional / medical problems? Choose an item. If yes, please describe:
Does the child or young person have a Learning Disability?Choose an item. If yes, please describe:
Is there any history of Urinary Tract Infection’s (UTI’s)?Choose an item. If yes, please detail history & treatment
On examination (if carried out):
  • Blood pressure:
  • Abdominal examination:
  • Results of urinalysis or urine culture:
N.B.urinalysis not routinely required unless the child or young person has started night time wetting recently (in the last few days or weeks), has daytime symptoms, any signs of ill health, history or signs/symptoms suggestive of urinary tract infection or diabetes mellitus.
Additional comments:
Referrer’s Details
Name:
Address:
Email address: / Contact No:
Date: / Signature:

Please send the completed form via secure email to . This is our preferred method for receiving referrals, but alternativelyit can be printed and sent to:

Suffolk County Council Night Time Wetting (Nocturnal Enuresis / Bedwetting) Service

Allington House

427 Woodbridge Road

Ipswich

Suffolk

IP4 4ER

SCC CH Night Time Wetting (Nocturnal Enuresis/Bedwetting) Service Referral Form Version number 1:0

Issued: 21/12/2017 Next review date: 21/12/2019Page 2 of 2