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Incontinence Samples for Men
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1
Your Email
*
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We'll use this to communicate with you about your samples
example@example.com
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2
Which insurance(s) do you have?
*
This field is required.
Medicare only
Medicare Advantage only
Medicare + Supplemental Insurance
Medicaid only
Private Insurance only (non-medicare advantage)
No Insurance
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3
Date of birth
*
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4
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5
How often does urine leak?
*
This field is required.
All the time
Several times per day
About once a day
Two/Three times a week
About once a week
Never
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6
How much urine do you usually leak (whether you wear protection or not)?
*
This field is required.
A large amount
A moderate amount
A small amount
None
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7
How much bladder leakage interferes with your regular life?
*
This field is required.
No interference
Minor interference
Moderate interference
Major interference
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8
When does urine leak?
*
This field is required.
Never - does not leak
Before I can get to the toilet
When I cough or sneeze
When I am sleeping
When I am physically active
When I finished urinating and am dressed
For no obvious reason
All the time
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