Continence Comprehensive Health and Life Assessment

The Continence Comprehensive Health and Life Assessment Questionnaire is part of a continuing effort to better understand adults (18 years of age or older) living with urinary incontinence, and their special needs. The questionnaire consists of questions concerning issues related to health, lifestyle, and support needs. Your complete response is important, and we ask that you answer every question to the best of your ability.

Thank you

1. What is today's date? Example: February 15, 2007 should be entered as 02/15/2007

2. Do you have

	stress urinary incontinence
	urge urinary incontinence
	mixed incontinence
	neurogenic bladder
	overactive bladder
	Do not know

3. Do you have any of the following

	heart disease
	spina bifida
	asthma
	spinal cord injury
	high blood pressure
	multiple sclerosis
	none of the above

4. Do you have, or have you had

	a stroke
	diabetes
	reoccuring urinary tract infections
	a hysterectomy
	prostate problems
	problems with bowel leakage
	none of the above