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Connecticut Children s Co-Management Tool-Kit 860. 545. 9000 www. connecticutchildrens. org PEDIATRIC VOIDING DYSFUNCTION CO-MANAGEMENT SPECIALIST FEEDBACK/TREATMENT PLAN Patient Name Patient DOB Age years and months Date of Visit Sex Male Female Accompanied by Pediatric Urologist Primary Care Provider Additional Urologic Diagnoses UTI Vesicoureteral Reflux Hydronephrosis Other Interval History Dysfunctional Voiding Symptom Score Voiding Interval Daytime wetting Yes No Episodes per day per...
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