CELLEBRATE: Stress Urinary Incontinence Study
Pre-Screening Questions

Your information will not be sold or shared with third parties for their own separate use.
1. How did you hear about us?  








2. What is your date of birth?
Month Day Year
3. It is important that you do not become pregnant during the course of the study. If asked to do so by study personnel, would you be willing to use an acceptable method of birth control or remain abstinent for the duration of the study? Acceptable methods of birth control will be explained by the study coordinator.



4. How many times per day do you experience urine leakage on effort or exertion, or on sneezing or coughing?




5. Have you previously tried pelvic floor muscle training, also known as PFMT?


6. Have you had surgical intervention in the pelvic area (e.g., surgery for stress urinary incontinence, mesh removal, prolapse surgery) in the last 6 months?

7. Have you ever received botulinum toxin treatment for your incontinence?