Horizons Clinical Research Center, LLC
Questionnaire
© Copyright 2007 Horizons Clinical Research Center, LLC / All Rights Reserved
    Questionnaire for those interested in participating in a research study for the treatment of
    overactive bladder.
How did you hear about us?
Are you female at least 18 but not older than 70 years of age?
 Yes
 No
Are you pregnant or breastfeeding?
 Yes
 No
Do you void at least 8 times in 24 hours?
 Yes
 No
Do you experience episodes of urge urinary incontinence?
 Yes
 No
Do you have history of urinary retention?
 Yes
 No
Do you have history of interstitial cystitis or bladder pain syndrome?
 Yes
 No
Have you had Urological surgery within the last 4 months?
 Yes
 No
Have you participated in a clinical study in the past 3 months?
 Yes
 No
Your name:
Your e-mail address:
Your phone number:
Comments:
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