Self-Assessment: Urinary Incontinence Urinary Incontinence is the loss of bladder control. This can vary from a slight loss of urine after sneezing, coughing, or laughing to complete inability to control urination. Tell Us About Your SymptomsDo you leak urine when sneezing, laughing or coughing?*YesNoDo you leak urine with jumping, lifting or exercise?*YesNoDo you experience strong urges to urinate that might lead to leakage if you can't get to a bathroom in time?*YesNoDo you have to empty your bladder more frequently than every 2-3 hours during the day?*YesNoAre you having to wear a pad or something else to absorb the leaking urine?*YesNoDo you regularly have to get up 2 or more times per night to urinate?*YesNoDo your symptoms create significant distress, interfere with your daily routine or cause you to avoid certain activities?*YesNoTell Us About YourselfName* First Last Phone Number*Email Address* I would like to receive a call to schedule a consultation with Dr Jones:*YesNo Is it urgent? Contact our office to schedule an appointment! Is it REALLY urgent? Call 911.