Bladder Survey

Name(Required)

First Last

Date of Birth (DOB)(Required)

Cell Phone(Required)

Home Phone

How long have you had a bladder problem?(Required)

How many times do you urinate in a day?(Required)

How often do you urinate during the day?(Required)

Multiple times per hour

Hourly

Every 1-2 hours

Every 2-3 hours

How many times do you get up at night to urinate?(Required)

On a scale of 0 to 10, how do you describe your urge to urinate?(Required)

Do you leak urine?(Required)

Yes

Occasionally

How many bladder leaks do you have per day?

Do you wear a pad?(Required)

Yes

How many pads do you use per day?

Do you wear diapers?(Required)

Yes

How many diapers do you use per day?

Bladder problems can have a negative impact on your quality of life. Check ALL boxes that apply.

Have you previously seen a physician about your bladder? Check ALL boxes that apply.

Family

Gynecologist

Urologist

Urogynecologist

Have you tried any of the following bladder control strategies? Check ALL boxes that apply.

Have you ever tried any of the following? Check ALL boxes that apply.

The following conditions might affect your ability to take overactive bladder (OAB) medications. Check ALL boxes that apply.

Johns Hopkins recommends that patients having 3 or more of the following problems should avoid certain OAB medications. Check ALL boxes that apply.

Muscle weakness

Slow walking speed

Decreased physical activity

Weight loss

Easily fatigued/tired

Poor balance/unsteady

Do you ever have accidents involving your bowels?(Required)

Yes

How often does this occur?

How long have your bowels been a problem?

Focused on Female Bladder/Bowel Dysfunction Pelvic Pain Minimally Invasive Surgery