Have you noticed discomfort or pain in your lower back, pelvic area, or groin? *

No, I feel fine

Occasionally, but nothing serious

Yes, it’s becoming a constant issue

Do you ever have sudden urges to urinate and struggle to hold it? *

No, I have full control

Sometimes, but I manage

Yes, it’s becoming embarrassing and frustrating

Have you experienced a decrease in sexual performance or interest? *

No, everything is normal

Sometimes, but I haven’t thought much of it

Yes, and it’s affecting my confidence

How often do you wake up at night to pee? *

Rarely, if ever

Sometimes (2-3 times)

Almost every night (4+ times)

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First Name *

Last Name *

Phone *

Email *

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