Bladder Symptom Survey

Name of Patient

Telephone

Doctor

What symptoms bother you the most?

Select all that apply

Select or enter value

How long have you been bothered by these symptoms?

Have you tried medications or therapies for these symptoms?

Selet all that apply

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Which medications?

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How much did medications help?

No help being the lowest number and complete resolution the higher number

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If you stopped taking medication, why?

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Please explain unwanted side effects

How frustrated are you with your bladder symptoms?

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Would you like to learn more about your treatment options?

Send me a copy of my responses