Consultants in Urology, PC
BLADDER SATISFACTION SURVEY
Which symptoms best describe you?
Frequent Urination — Day, Night, or Both
Leaking with Sneezing, Coughing, Exercising
Sudden or Strong Urge to urinate
Leaking with Urge or No Warning - Unable to make it to the bathroom in time
Unable to Empty the Bladder
Bladder or Pelvic Pain
How long have you had these symptoms?
Have you tried medications to help your symptoms?
If yes, check the medications you have tried:
Did these medications help your symptoms? Select #
No Relief -
- Completely Cured
If you have stopped taking your medications explain why:
Did not Help
Describe Side Effects
Behavior Modifications Tried
(i.e., caffeine intake, lifestyle changes, bladder training, pelvic floor muscle training)
What is your level of frustration with your bladder symptoms? Select #
Not Frustrated -
- Very Frustrated
If you had to live the rest of your life with these symptoms, would that be acceptable?
Date of the survey
Type your email (confidentiality is guaranteed)
Thank you for taking the Bladder Health & Wellness Survey! Your answers to the survey were sent to your email. Thank you!