Stress Urinary Incontinence (SUI) Research Interview
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
-
Country Code
Phone Number
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1) What is your age?
*
2) What is your current employment status?
*
Employed Full-time
Employed Part-time
Unemployed
Self-employed
Retired
Other
If Other, please specify
3) Do you identify as pre-menopausal, menopausal, or post-menopausal?
*
Pre-menopausal
Menopausal
Post-menopausal
4) Do you experience pee (urine) leaks while performing any physical activity like sneezing, coughing, or jumping?
*
Yes
No
5) Have you been diagnosed with Stress Urinary Incontinence(SUI) by a doctor?
*
Yes
No
6) How long have you been experiencing symptoms of stress urinary incontinence?
*
Less than 1 year
1-3 years
3-5 years
More than 5 years
7) What triggers your urinary incontinence (pee/urine leaks)? (Select all that apply)
*
Physical activity (e.g., exercise, sneezing, laughing, etc.)
Coughing
Heavy lifting/Lifting children
Other
If Other, please specify
8) How would you rate the severity of your urinary incontinence symptoms?
*
Mild
Moderate
Severe
Extreme
9) How frequently do you experience urinary incontinence?
*
Daily
Frequently (once a week)
Occasionally (a few times a month)
Rarely (once a month or less)
10) How do these symptoms impact your daily life? (Select all that apply)
*
Difficulty in performing daily tasks
Interference with work or social life
Affecting mental health
Disruption of sleep patterns
11) Have you looked for any treatment or advice for your urinary incontinence?
*
Yes
No
12) If yes, what type of treatment have you explored? (Select all that apply)
*
Pelvic floor exercises
Medications
Surgery
Lifestyle changes (diet, weight management)
Other
If Other, please specify
13) If no, would you like to get help from a trained professional?
*
Yes, please
No, I prefer to do it on my own
14) How important is it for you to avoid bladder leaks during real-life movements like lifting children or heavy weights, walking, or sneezing?
*
Extremely important
Important
Not important
15) What do you find most helpful in managing your symptoms?
0/100
16) Would you like to share any additional comments or insights about your experience with stress urinary incontinence?
0/150
17) Would you like to participate in a follow-up interview for a more in-depth discussion?
*
Yes, sure!
No, thank you!
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