Are you experiencing one or some of the following? (Check all that apply and hit next)
Sudden urge to urinate with little or no warning?
Accidental loss of small amounts of urine?
Uncomfortable Urination
Do you Wake Up 2 or More Times A Night To Urinate?
Do you Urinate more than 8 times in 24 hours?
Urine loss associated with a strong desire to urinate?
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Sudden urge to urinate with little or no warning?
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Uncomfortable Urination
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Accidental loss of small amounts of urine?
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Nighttime Urination?
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Waking up at night because you had to urinate?
During the past 4 weeks, how bothered were you by...
Please use a scale of 1-6, 1 being not at all and 6 being a lot.
Urine loss associated with a strong desire to urinate?
If you spent the rest of your life with your urinary condition the way it is now, how would you feel?
Please use a scale of 1-6, 1 being delighted and 6 being terrible..
I would feel...
Do you have Medicare?
Yes
No
I have a Medicare Replacement Plan
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