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CONTACT
ABOUT
MORE
- SHOP
- FAQS
- VIDEOS

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INCONTINENCE/QUALITY OF LIFE QUESTIONNAIRE

INCONTINENCE/
QUALITY OF LIFE QUESTIONNAIRE

When answering the following questions, think about how you have been, in general, over the PAST FOUR WEEKS.

How often do you leak urine?

Never
About once a week or less often
Two or three times a week
About once a day
Several times a day
All the time

About how much urine do you usually leak (whether you wear protection or not)?

None
A small amount
A moderate amount
A large amount

Overall, how much does leaking urine interfere with your everyday life? Please select a number between 0 (not at all) and 10 (a great deal).

When does urine leak? (Please select all that apply)

Never. My urine does not leak.
Leaks before I can get to the toilet.
Leaks when I cough or sneeze.
Leaks when I sleep.
Leaks when I'm physically active/exercising.
Leaks when I've finished urinating and are dressed.
Leaks for no obvious reason.
Leaks all the time.

Gender

Female
Male

Name

Email *

Phone Number

Date of Birth

How Did You Hear About Us?

Message

Pages

Executive Physical
Genomic and Biological Age
Ultra Health Membership
IV Vitamin Power Infusion
Far Infrared Sauna
Liver Detoxification
Hyperbaric Oxygen Therapy
Aesthetic Services
Sexual Enhancement/Incontinence

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Glutathione Boost
Vaginal Atrophy
Chelation Therapy
Microneedling
Platelet-Rich Plasma Therapy
Regenerative Therapy
Skin Care Management
Lasting Medical Weight Loss
Advanced Cardiac Program

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Sleep Issues
Heart Disease Prevention
Laser Skin Resurfacing
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DISCLAIMERS

DISCLAIMERS:
Therapies and services are subject to change based upon your specific needs, which are determined by labs and Dr. Habib’s recommendations.

You should not use the info contained on this site for diagnosing a health problem or prescribing a medication. You should carefully read all info provided by the manufacturers of the products on or in the product packaging and labels before using any product purchased on the site. Individual results may vary. Consult your physician. Info regarding dietary supplements have not been evaluated by the FDA and are not intended to diagnose, treat, cure or prevent any disease.

PROGRAMS
SERVICES
WHY NEXT HEALTH
TESTIMONIALS
CONTACT
ABOUT
MORE
- SHOP
- FAQS
- VIDEOS

We use the best tools in the healing arts to provide a precision diagnosis, primarily drug-free treatment, and treatment success that far exceeds traditional medicine.

ADDRESS

44121 Harry Byrd Highway
Suite #115
Ashburn, VA 20147

PHONE

703-724-4000

EMAIL

info@nexthealthmed.com

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