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UUI Clinical Study: Pre-Study Questionnaire 1
Part 1 (5 Minutes)
*
1.
What is your name?
(Required.)
Name:
*
2.
How old are you?
(Required.)
*
3.
How many years have you had incontinence?
(Required.)
*
4.
How many
urge
incontinence accidents/incidents do you have a
WEEK
? (leaks due to sudden urge to use the toilet)
(Required.)
*
5.
How many stress incontinence accidents/incidents do you have a
WEEK
? (accidents due to coughing, movement, etc)
(Required.)
*
6.
How many absorbent pads do you typically go through in a day?
(Required.)
7.
List ongoing therapies to treat your incontinence (if any).
*
8.
How do you currently manage your incontinence symptoms (e.g. absorbent pads, frequent bathroom visits, diet)
(Required.)
*
9.
Have you previously tried Kegel exercises to treat your incontinence?
(Required.)
Yes
No
If so:
How long ago?
How often did you perform them?
How did they work?
Was it under the direction of a healthcare provider?
