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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