Bladder Function Questionnaire

Determining Your Condition and Your Treatment, Important Information to Share with your Doctor

If you suspect you may have a bladder problem, you may have symptoms that range from simple dripping, to sudden urges, to total loss of bladder control. Or, maybe you don’t have a bladder condition, but you have a physical condition that restricts your ability to get to the bathroom safely and independently.

It’s always important to keep your doctor informed on any symptoms you may be experiencing so that you can maintain a comfortable, safe, and healthy lifestyle.

UrAssist may help if you or your loved one suffers from a bladder condition or mobility limitations.

To help you and your doctor determine your condition, your safety, and if UrAssist is a suitable option for you, we’ve created a brief questionnaire.

Questionnaire Print this out, answer the questions, and share this with your physician to determine if you have a bladder condition or mobility challenges that affect your ability to get to the bathroom.
Bladder Diary Print this out and use it to help you keep track of bladder frequency and symptoms, and share it with your doctor.
Letter For Your Doctor Print this letter that explains how UrAssist works and how it may be beneficial for your condition and share it with your physician.

If you or your doctor have any questions about UrAssist, call Toll Free, 1-866-381-4134, and a representative will be happy to assist you.

Always consult your doctor.

These tools are to help assist you in documenting symptoms so that you can share them with your physician. They are not intended to provide or replace medical advice from any healthcare provider. If you are experiencing difficulties with your bladder or mobility challenges, please contact your physician immediately.