Urinary Incontinence Test

Answer the following questions about yourself:

1.
Do you experience urine leaks several times a week?
Yes
No
2.
Do you leak at night when you are asleep?
Yes
No
3.
Do you experience urine leak when you are exercising or in sports activity?
Yes
No
4.
Do you leak urine when you cough, sneeze, or laugh?
Yes
No
5.
Do you often leak urine when you lift up heavy objects?
Yes
No
6.
Do you acquire sudden and unpredictable urges to urinate or leak for no obvious reason?
Yes
No
7.
Do you leak when you don't arrive at the toilet in time?
Yes
No
8.
Does the leaking bother you a lot and/or does it prevent you from doing what you want?
Yes
No
9.
Has urine leak significantly reduced your quality of life?
Yes
No
10.
Is urine leak affecting your professional life/career and/or daily obligations; meaning that you sometimes have to leave work early to address this issue or take more time off than most people?
Yes
No
Please answer all of the questions before continuing.

Please provide us with your contact information to email your test results.

First Name:
Last Name:
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