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Name
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Contact Number
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Location
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Do you experience urine leakage during physical activities such as coughing, sneezing, laughing, or exercise?
Yes
No
Sometimes
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Have you noticed frequent or sudden urges to urinate that you sometimes can't control, resulting in leakage?
Yes
No
Sometimes
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Do you often have to rush to the bathroom, fearing that you might not make it in time?
Yes
No
Sometimes
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Have you experienced urine leakage while lifting heavy objects or engaging in strenuous activities?
Yes
No
Sometimes
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Have you noticed any changes in your urinary habits after pregnancy or childbirth?
Yes
No
Sometimes
Next
Do you avoid social situations or activities that could potentially trigger urine leakage?
Yes
No
Sometimes
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