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100% of survey complete.

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* 1. Name:

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* 2. Phone #:

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* 3. Which symptoms best describe you?

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* 4. How long have you had these symptoms?

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* 5. Have you tried medications to help your symptoms?

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* 6. If yes, check the medications you have tried:

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* 7. Did these medications help your symptoms?

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* 8. If you’ve stopped taking your meds explain why:

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* 9. Behavior Modifications Tried:

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* 10. What is your level of frustration with your bladder symptoms?

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* 11. Do you currently have any problems with bowel function?

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* 12. Are you interested in learning more about treatment alternatives to medication?

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