EMSELLA QUESTIONAIRE

Name *

First Name

Last Name

Do you have a Neural Pathology or symptoms such as Pins & Needles/Numbness *

Yes

No

Do you have a UTI (Urinary Tract Infection) *

Yes

No

Are you currently menstruating *

Yes

No

Are you or pregnant or have you had a baby in the past 3 months? *

Yes

No

Do you have any Cardiac Pacemakers/Implanted defibrillators or neurostimulators *

Yes

No

Do you have any Electronic or Metal Implants/ Drug Pumps *

Yes

No

Do you have Pulmonary insufficiency/Heart Disorders/ Hemorrhagic Conditions/ Anticoagulation Therapy *

Yes

No

History of Cancer *

Yes

No

Have you had any Recent Surgery over the past 4 months? *

Yes

No

Are you currently taking any Medications *

Yes

No

Do you have any Skin Conditions or Sensitivities *

Yes

No

1. How many times do you pass urine in a day? *

0-7

8-10

11-15

Over 15

2. How many times do you get up at night to pass urine *

0-1

2

3

More than 3

3. Do you wet the bed before you wake up at night? *

Never

Occasionally - less than 1 per week

Frequently - once or more than once per week

Always - every night

4. Do you need to rush/hurry to pass urine when you get the urge? *

Can hold on

Occasionally but have to rush to the bathroom

Frequently have to rush

Daily

5. Does urine leak when you rush or hurry to the toilet or can't get there in time? *

Not at all

Occasionally - less than once per week

Frequently - once or more per week

Daily

6. Do you leak with coughing, sneezing, laughing or exercising? *

Never

Occasionally - less than once per week

Frequently - once or more per week

Daily

7. Is your urinary stream (urine flow) weak, prolonged or slow? *

Never

Occasionally - less than once per week

Frequently - once or more per week

Daily

8. * Do you have a feeling of incomplete bladder emptying? *

Never

Occasionally - less than once per week

Frequently - once or more per week

Daily

9. Do you need to strain to empty your bladder? *

Never

Occasionally - less than once per week

Frequently - once or more per week

Daily

10. Do you have to wear pads because of urinary leakage? *

Never

Sometimes as a precaution

When exercising or during cold weather

Daily

11. Do you limit your fluid intake to decrease urinary leakage? *

Never

Before Going Out

Moderately

Always

12. Do you have frequent bladder infections? *

No

1-3 times per year

4-12

More than 12

Checkbox

Option 1

Option 2