Patient Information
* Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Please answer the following questions regarding your bladder health.
* How often do you urinate during the day?
* How often do you get up at night to urinate?
* Do you usually have a strong sense of urgency to urinate?
* Do you have pain or pressure in the bladder that is relieved by urinating?
* Can you postpone emptying your bladder easily?
* Can you overcome the sensation of urgency to urinate?
* Is your urinary flow intermittent (stop and go)?
* Does the sight, sound, or feel of running water cause you to lose your urine?
* Describe the nature of your leak (mark all that apply) .
* Do you find it necessary to wear protection because you get wet from the urine that you lose?
* How many pads do you use daily?
* Do you change the pad when it is:
* When urinating, can you usually stop your stream?
* Do you ever accidentally wet the bed at night while asleep?
* Do you feel that you completely empty your bladder?
* Do you notice dribbling of urine when you stand after urinating?
* Were you ever catheterized because you were unable to void?
* Have you ever been treated by urethral dilations?
* Do you ever pass blood in your urine?
* Have you ever passed sand, gravel, or stones?
* Do you have pain during urination?
* Do you have difficulty starting your stream?
* How do you start your flow?
* Have you been treated for 3 or more urinary infections?
* Have you been treated for a bladder infection within the last 6 months?
Bowel Health
Please answer the following questions regarding your bowel health.
* How would you describe your bowel movements?
* Have you ever passed stool when you thought it might be gas?
General Health
* Do you have (or had in the past) any of the following (mark all that apply) ?
Women's Health
Please answer the following questions regarding your health.
* How many live births have you had?
Did your urinary difficulty begin:
* During a pregnancy?
* Following a pregnancy?
* Have you had a hysterectomy?
* Was it vaginal?
* Or abdominal?