Continence Care Questionnaire // Sample Request Form

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Are you interested in trying a few continence care products? If so, you're in the right place! By filling out this form, you help us assess your current situation and needs in order to provide you with the products that will most likely be the right fit for you!

Email *

If you'd like to fill out a digital copy of this form & have it submitted directly to us, scan the QR code below. If you prefer to fill out this paper copy, please email it to kat.w@moosemobilitymedical.com

First Name *

Last Name *

Phone Number *

Full Address (including city, province, postal code) *

What is your sex? *

Male

Female

Are you currently using any continence care products? *

Yes

If you answered, "Yes" above, please tell us what products you are currently using & how often you are changing the current product

What type of incontinence do you experience? *

Stress Urinary Incontinence: intermittent, slight leak of urine when pressure is on the bladder from standing, coughing, sneezing, and laughing

Over Active Bladder (OAB): the leaking of urine with the sudden uncontrollable urge to empty that cannot be delayed, even if the bladder is not full

Mix Incontinence: a mix of Stress & OAB

Overflow Incontinence: leaking or dribbling that occurs with or without warning

Reflex: neological impairment that can contract the bladder muscle without warning

Total: no physical ability to control urine loss

Bowel Urge Fecal Incontinence: feeling the need to go but cannot control the release in time to reach the bathroom

Bowel Fecal Incontinence: cannot control and unaware of bowel movements

I'm Not Sure

Required

What is your level of incontinence? (How much urine is lost within a 4 hour period). *

Light (up to 3 fl oz/100mL)

Normal/Moderate (3-7 fl oz/100-200mL)

Heavy or All at Once (frequent & abundant with lack of control)

Do you struggle with bowel control? (Select if answer is yes)

I'm Not Sure

Required

How do you void? *

Slow

Steady

Fast & Heavy

I'm Not Sure

Required

What is your mobility level? *

Mobile & Active

Mobile but with an aid (walker, cane, wheelchair, scooter, powerchair)

Immobile or bedridden

Required

What is your waist measurement in inches? *

What is your hip measurement in inches? *

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