Research Survey | The Canadian Continence Foundation

Research Survey

Participate in Incontinence Research

Please complete the following questionnaire, to assist The Canadian Continence Foundation gather important statistics on urinary incontinence. By completing this survey we will collect important information to enhance our lobbying efforts on your behalf.

All information gathered will remain the property of The Canadian Continence Foundation and only overall statistics will be used.


Age:
 
 male     female
Province/State:
Country:
Have you ever experienced involuntary urine leakage?     Yes       No
If yes, do you suffer from urge incontinence?    Yes     No      Not sure
Stress incontinence?   Yes       No     Not sure
Or other – please specify
Have you consulted a health care professional?   Yes     No
If no, why not?
How long did you wait before consulting a professional?
What prevented you from seeking professional help initially?
What type of healthcare professional(s) did you see?
Family Physician Urologist
Gynecologist Geriatrician
Urogynecologist Nurse Continence Advisor
Physiotherapist Alternative medicine practitioner
Other  

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PO Box 417
Peterborough ON K9J 6Z3
Phone: (705) 750-4600
Email: help at canadiancontinence dot ca
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