Evaluation Form

The diagnosis form is suitable for bedwetters ages 4-20. If the individual is older than 20 or if he or she suffers from medical, psychological or other issues that you feel affect the bedwetting issue, please use the “Contact us” form and elaborate about the bedwetting condition.

Please fill out the assessment form and Dr. Sagie will personally evaluate your child’s bedwetting condition.

E-mail (the assessment will be sent to this e-mail) *

Country *

Child's age *

Gender *

Secondary enuresis - Was your child ever dry at night for six months or more? *

Bedwetting frequency per week (providing that your child is not taken to the bathroom while he/she is asleep and there is no fluid restriction before bed-time) *

Does your child dribble (wet spot on his/her underwear or clothes) during the day? *

Depth of sleep- Is your child a deep sleeper? *

Genetic factor – Did a member or members of your family (parents, siblings, relatives of first degree) suffer from bedwetting *

Previous or current interventions or treatments for bedwetting, Did you wake up your child at night? *

Did you limit your child's fluid intake before bed time? *

Did you try a bedwetting alarm? *

Did you try any medications (DDAVP, Tofranil, Oxibutinin, or other drugs)? *

Does your child still wear pull-ups at night? *

How did you hear about us? *

(You have to answer this question for anti-spam purposes)How much is three times two? * Your answer is not correct

Disclosure: By clicking send you agree to give your email address to Dr. Sagie’s Bedwetting Clinics for the purpose of receiving an email with your child’s evaluation including updates about bedwetting. You can choose to stop receiving these emails at any time.

Evaluation Form

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