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Study Screener

Name:
How did you hear about this website?	Select one Craigs List Internet Search Email Television Radio Newspaper Mail - postcard Someone told you Other
Email Address:
What is your address? (Street, city, State/Province)
What is your postal Code?
What is the best phone number to contact you? (please include area code)
What is your age?
Over the past six months, have you experienced the sudden, strong urge to urinate?	Yes No
Has your sudden urge to urinate resulted in incontinence or loss some urine before you could make it to the bathroom?	Yes No Unknown
Are you currently taking medication for your overactive bladder?	Yes No Unknown
Within the past year, how many separate, diagnosed urinary tract infections have you experienced?	None One Two Three or more
In the past year, have you had genital herpes or vaginal warts?	Yes No Unknown
Have you had Toxic Shock Syndrome?	Yes No Unknown
Do you currently use a catheter?	Yes No Unknown
In the past five years, have you been diagnosed with or treated for bladder cancer?	Yes No Unknown
Have you participated in another clinical trial in the past 30 days?	Yes No
If you pre-qualify for this study based on your answers provided, may we contact you at the phone numbers you provided?	Yes No

 

Based on the answers you provided, if you prequalify, a study coordinator will contact you within 24-48 hours during the work week. The study coordinator may ask you additional questions and may need to take lab tests to determine if you further qualify for the study.  If you do not prequalify, the information you provided during this session will be destroyed immediately.