Patient Incontinence Questionnaire

Do you experience uncomfortable urges to urinate? *

Do you ever experience a sudden urge to urinate with little to no warning? *

Do you experience urine loss along with the strong desire to urinate? *

Do you have to get up at night to urinate *

Do you experience leakage while laughing, sneezing, jumping or performing other movements that put pressure on the bladder? *

Has your bladder control caused you to plan "escape routes" to restrooms in public places? *

Do you have trouble holding your urine as you hurry to the bathroom? *

Have your urinary symptoms affected your relationship with your partner/family or friends? *

Has your bladder control issue caused you embarrassment or anxiety? *

What is your name? *

What is your e-mail address? *

What is the best number to use to reach you? *

Are you male or female? *

Questions / Comments?

How did you hear about us? *