Toggle navigation
Call us: 651-600-3035
Get an Appointment
Patient Portal Login
Our Services
Our Providers
About us
Patient info
Join Our Team
View/Pay Account
Urogynecology Treatment Effectiveness Survey
Your First Name
Required
Date of birth
Required
What bladder, bowel, or pelvic floor problems have you experienced in the past 24 months? (select all that apply)
Required
Frequent urination (8 or more times a day)
Get up more than once a night to urinate
Sudden or strong urge to urinate
Leakage with little or no warning – sometimes unable to make it to the bathroom in time
Unable to completely empty bladder – feels like there is more even after going to the bathroom
Accidental leakage with physical activity (exercising, sneezing or coughing)
Bladder or pelvic pain
Accidental loss or leakage of stool – sometimes unable to make it to the bathroom in time
Accidental loss of gas
Constipation
Frequent, loose, watery stools
Sudden or strong urge for a bowel movement
None
Have you tried any of these behavioral modifications? (select all that apply)
Required
Lifestyle changes
Diet changes
Pelvic floor training exercise
None
Other
If you answered "other," what else have you tried?
Have you tried medications to help your symptoms?
Required
Yes
No
If yes, please indicate which medication(s) you've tried:
How much relief have the medications provided to you?
Required
None. Nothing changed.
A small amount of improvement.
About 50/50. I'm okay sometimes.
Quite a bit. Most of the time, I am symptom-free.
Complete relief.
I have never taken medication for my condition.
Are you still taking medications for your condition?
Required
Yes
No
I have never taken medication.
If no, why did you stop taking your medication? (select all that apply)
Did not work as well as expected
Interaction with other medications
Side effects
Expense
I no longer needed it.
Other
Please indicate if you have had medical treatment (other than medication) for one of these conditions in the past: (select all that apply)
Required
Frequent urination (8 or more times a day)
Get up more than once a night to urinate
Sudden or strong urge to urinate
Leakage with little or no warning – sometimes unable to make it to the bathroom in time
Unable to completely empty bladder – feels like there is more even after going to the bathroom
Accidental leakage with physical activity (exercising, sneezing or coughing)
Bladder or pelvic pain
Accidental loss or leakage of stool – sometimes unable to make it to the bathroom in time
Accidental loss of gas
Constipation
Frequent, loose, watery stools
Sudden or strong urge for a bowel movement
Have not had treatment
What medical treatment did you have?
Required
How much impact did the medical treatment have on your symptoms?
Required
None. Nothing changed.
A small amount of improvement.
About 50/50. I'm okay sometimes.
Quite a bit. Most of the time, I am symptom-free.
Complete relief.
I have never had medical treatment for my condition.
How would you describe your current level of frustration with your bladder, bowel, or pelvic floor symptoms?
Required
I'm not frustrated at all.
Sometimes I'm frustrated, but not often.
About half of the time it's a problem.
I'm bothered by it most of the time.
It's a constant concern and source of frustration.
Do you want to know when products and techniques to control your condition become available?
Required
Yes
No
When there is new information that may be of interest to you, how can we best reach you?
Is there anything else we should know that will help us better understand your condition or treatment?
Please type the letters and numbers shown in the image. Click the image to see another captcha.
Helpful Info
What is Urogynecology?
Treatment for Female Urinary Incontinence
Urogynecology & Surgical Reconstruction
Urogynecology: About Pelvic Organ Prolapse
Urogynecology: Treatment for Bladder Problems
Surgical Treatment for Urinary Incontinence
What is a Urodynamic Study?
Repair for Pelvic Organ Prolapse
Treatment for Bladder Problems in Women
Interstitial Cystitis (IC) Diet
Recurrent Urinary Tract Infections (UTIs)
What is InterStim Therapy?
InTone
Female Pelvic Solutions
SoLá Pelvic Therapy for Pelvic Pain
Chronic Pelvic Pain - Info & Treatment
Bladder Control with Axonics