Bladder Satisfaction Survey Page1 / 1 100% of survey complete. Question Title * 1. Name: Question Title * 2. Phone #: Question Title * 3. Which symptoms best describe you? Frequent Urination – Day, Night, or Both Sudden or Strong Urge to urinate Unable to Empty the Bladder Bladder or Pelvic Pain Leaking with Sneezing, Coughing, Exercising Leaking with Urge or No Warning (Unable to make it to the bathroom) Question Title * 4. How long have you had these symptoms? Question Title * 5. Have you tried medications to help your symptoms? Yes No Question Title * 6. If yes, check the medications you have tried: Detrol LA Ditropan XL Flomax Cardura Myrbetric Oxytrol Patch Enablex VESIcare DDAVP Sanctura Elavil Any over the counter medication purchased for urinary frequency or Urgency Other (please specify) Question Title * 7. Did these medications help your symptoms? No Relief 1 2 3 4 5 6 7 8 9 Completely Cured No Relief 1 2 3 4 5 6 7 8 9 Completely Cured Question Title * 8. If you’ve stopped taking your meds explain why: Did not help Side Effects Too Expensive Describe Side Effects: Question Title * 9. Behavior Modifications Tried: Caffeine Intake Lifestyle Changes Bladder Training Pelvic Floor Muscle Training Other (please specify) Question Title * 10. What is your level of frustration with your bladder symptoms? Not Frustrated 1 2 3 4 5 6 7 8 9 Very Frustrated Not Frustrated 1 2 3 4 5 6 7 8 9 Very Frustrated Question Title * 11. Do you currently have any problems with bowel function? Fecal Incontinence Constipation Other (please specify) Question Title * 12. Are you interested in learning more about treatment alternatives to medication? Yes No Done