Urinary Incontinence Questionnaire Question Title * 1. What is your age? Question Title * 2. What is your gender? Question Title * 3. How much discomfort does your incontinence cause you? 1- No discomfort 2- Minor discomfort 3- Moderate discomfort 4- Severe, but tolerable discomfort 5- Severe, intolerable discomfort 1- No discomfort 2- Minor discomfort 3- Moderate discomfort 4- Severe, but tolerable discomfort 5- Severe, intolerable discomfort Question Title * 4. How much stress does your incontinence cause you? 1- No stress 2- Minor stress 3- Moderate stress 4- Severe stress 5- Debilitating stress 1- No stress 2- Minor stress 3- Moderate stress 4- Severe stress 5- Debilitating stress Question Title * 5. How frequently does this problem occur? Hourly Daily Weekly Monthly Yearly Hourly Daily Weekly Monthly Yearly Other (please specify) Question Title * 6. If there was a method/device that would allow you to solve your problem, would you be willing to pay 250 dollars for it? Yes No Question Title * 7. Would you be willing to have a 10-15 minute confidential phone conversation with us to answer a few more questions on this topic? If so, please provide your email. Yes No Preferred Email Done