Continence Survey

Thank you for taking the time to complete this questionnaire to enable us to assess your continence level. Please tick yes or no to each question.

All fields are required.

First Name

Surname

Address

Date of Birth

Contact Phone Number

Email Address

Are you a new client?
YesNo

Are you a member of a health fund?
YesNo

Workers Compensation?
YesNo

Third Party Insurance?
YesNo



Question.


If you cough or sneeze do you leak urine?
YesNo

Do you have a sudden strong urge to pass urine?
YesNo

Are you emptying your bladder often?
YesNo

Do you leak urine before getting to the toilet?
YesNo

Do you feel like you have not emptied your bladder completely?YesNo

Do you strain when you open your bowels?
YesNo

Are your stools hard pieces?
YesNo

Can you control wind?
YesNo

Is there any soiling on your underwear?
YesNo

Do you get up more than twice a night?
YesNo

Do you feel pain while passing urine?
YesNo

Do you have a weak flow?
YesNo

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If you answered yes to any of these questions, you have a continence problem.

Did you realise most continence problems can be improved without surgery?

If you would like information on improving your continence situation please click on the contact us section.

All fields are required.

First Name

Surname

Address

Date of Birth

Contact Phone Number

Email Address

Appointment Date

Appointment Time

Alternative Date

Alternative Time

Are You A New Client?
YesNo

Are You A Member of a Health Fund?
YesNo

Workers Compensation?
YesNo

Third Party Insurance?
YesNo

Service Required

Area of Concern / Body Part

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