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A Brief Test for Female Urinary Control and Energy Levels
This brief test can help you evaluate BetterWOMAN. Print out this form and take a test before you start taking BetterWOMAN and then again after you finish your first 4 bottles. You will see yourself whether BetterWOMAN has helped you. Use BetterWOMAN as directed.
| Female Urinary Control and Energy Level Inventory |
Score Definition |
Before Taking Date: _______
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After 3
Bottles
Date: _______ |
| 1. During the past 30 days, how often did you feel "leaking"
when you coughing, laughing, sneezing, bending, or exercising? |
0 = Never
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Always |
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| 2. During the past 30 days, how often did you feel the
abrupt urgency to urinate? |
0 = Never
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Always |
|
|
| 3. During the past 30 days, how often did you feel you
had to go all the time? |
0 = Never
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Always |
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| 4. During the past 30 days, how often did you feel you
were exhausted? |
0 = Never
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Always |
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| 5. During the past 30 days, how often did you feel you
were tired? |
0 = Never
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Always |
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In what area(s) did BetterWOMAN help you?
• Improving urinary control ______Yes _____No _____Not sure
• Improving energy levels _____Yes _____No _____Not sure
Name: __________________________ Age: _____ Phone#:_____________
Comments or Suggestions: ___________________________
_________________________________________________
We care about your results. Please mail us a copy of your completed form
to BetterWOMAN, PO Box 392, Marblehead, MA 01945. All information will
be kept confidential. Thank you.
 
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Call 888-686-2698 to order.