Are you experiencing incontinence issues right now?

Yes

No

How often do you experience incontinence issues?
Please select your option

It began not long ago

About Six months or less

A period of six months to a period of two years

2 years and counting

Have you seen a doctor about your incontinence condition?
If you have, what was is the main reason of your incontinence and your doctor's recommendation?
If not, what has kept you from obtaining expert help and do you intend to seek for further medical advice regarding the condition?
Do you require assistance?

Yes

No

Do select the any of following symptoms that you may be experiencing:
You can choose one or more options

When your bladder is put under extra sudden pressure say from coughing

sneezing

hard lifting; or exercise

you may leak pee.

You have an urgent need to pass urine and you can't wait to go to the bathroom.

Urinary retention occurs when the bladder does not empty completely upon passing urine.

Difficulty passing all the urine

Do you have to urinate frequently in the middle of the night?
If you answered yes, please estimate how many times you need to get up to urinate during a regular night.

Yes

No

Do you experience any discomfort when passing urine?

Yes

No

Do you get cystitis (bladder infections) on a regular basis?
If you answered yes, please describe how frequently you have bladder infections and how severe they are.

Yes

No

Has a doctor examined your prostrates lately?
This question must only be answered by men. Women, please answer "yes"

Yes

No

Do you use water pills like diuretics, furosemide or bendroflumethiazide?

Yes

No

Have undergone a diabetes examination or do you already have it?
If you do have diabetes, please provide us with as much information as you can regarding your diagnosis or test.
If the answer is no, we recommend getting a diabetic screening test from your doctor or local drugstore (fasting blood sugar).

Yes

No

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

Is your doctor now prescribing Vesicare 5mg Tablets to treat urinary incontinence?
Do you require assistance?

Yes

No

Have you experiencing any side effects as a result of your treatment?

Yes

No

Have you been taking Vesicare 5mg Tablets for a long time?
Please select your option

3 months or less

From 3 to 12 months

For more than a year

It is not currently recommended.

Do you have any of the following problems:
A complete inability to pass pee or a great deal of trouble passing urine.
Any stomach or intestinal problem that is serious.
Myasthenia gravis is a kind of myasthenia.
Glaucoma.
Constipation.
Hernia hiatus.

Yes

No

Does any of the following statements apply to you:
Orlistat causes an allergic reaction or hypersensitivity in you.
You've previously used Orlistat and experienced serious side effects.
You are experiencing rectal bleeding.
You have chronic malabsorption syndrome, which has been identified by a doctor.
You have been diagnosed with cholestasis (condition where the flow of bile from the liver is blocked)

Yes

No

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or using any medication?

Please provide more information of the medication being used if any.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

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