Clinical Study for Urge Urinary Incontinence - Screening

The purpose of these questionnaire is to determine if you are eligible to participate in the clinical study. These questions should take about 5 minutes to complete. Please answer everything truthfully. Contact director@elitonestudy.com if you have questions.

Question Title

Who are you? (your information is kept confidential)

First Name:

Last Name:

Email:

Phone:

Question Title

Are You Female?

Yes

No

Question Title

Is it very difficult to control when you have a strong urge to urinate?

Yes

No

Question Title

Do you lose urine with physical activities such as coughing, sneezing, or running?

Yes

No

Question Title

Are MORE of your incontinence episodes due to a strong urge to urinate than to abdominal pressure such as coughing, sneezing, or running?

Yes

No

Question Title

How many accidents (leaks) do you average a day.

Question Title

What is your age?

Question Title

What is your height?

Question Title

What is your current weight in pounds? (needed to calculate BMI)

Question Title

Find your height and weight in this chart. Your BMI is displayed where the column and row meet. Where is your BMI on the chart?

in white area, BMI<35

in yellow-orange area, BMI ≥ 35

Question Title

BMI Chart

BMI Chart