Do you occasionally dribble or leak when you sneeze, cough or exercise?
Yes No
Do you feel urinary urgency (feeling that you have to go to the bathroom)?
Yes No
Are you being treated for incontinence with medications or pelvic floor therapy?
Yes No
Are you currently being treated with hormones/estrogen?
Yes No
Do you feel loose vaginally since childbirth or menopause?
Yes No
Do you feel dry during intercourse? Have trouble reaching orgasm?
Yes No
Have your intimate relationships suffered due to any of the above?
Yes No
If there was an in office, non-surgical treatment solution that is painless, with no downtime that could help with many of these issues would you be interested?
Yes No
If over 90% of women suffering from laxity, dryness, incontinence, and sexual dysfunction found this treatment to be effective and worth the cost would you consider speaking with the doctor about this treatment?
Yes No