Bladder Satisfaction Survey Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Your phone numberDoctor Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Your email CAPTCHAWhich symptoms best describe you? Frequent Urination – Day, Night, or Both Sudden or Strong Urge to urinate Unable to Empty Bladder Leaking with Sneezing, Coughing, Exercising Leaking with Urge or No Warning (unable to make it to the bathroom) Bladder or Pelvic Pain How long have you had these symptoms?Have you tried medications to help your symptoms?YesNoCheck the medications you have tried: Detrol LA Oxytrol Patch Sanctura Ditropan XL Enablex Elavil Flomax VESIcare Elmiron Cardura DDAVP Other Did these medications help your symptoms? Scale of 1 to 10 with 10 being ‘Completely Cured’12345678910If you’ve stopped taking your meds explain why:Behavior Modifications Tried:(i.e. caffeine intake, lifestyle change, bladder training, pelvic floor muscle training)What is your level of frustration with your bladder symptoms?12345678910Scale of 1 to 10 with 10 being ‘Very Frustrated’Do you currently have any problems with bowel function?Fecal IncontinenceConstipationOtherI am interested in learning more about treatment alternatives to medications:YesNo Δ