Do you know whether or not you have a shy bladder?

  Yes, I do
  No, I do not
  I choose not to answer

Are you nervous while urinating in public restrooms?

  Yes
  No
  I choose not to answer

Are you ever in situations where you can't urinate no matter how hard you try even though you have to go?

  Yes
  No
  I choose not to answer

Would you urinate more easily if there was noise being made while you were going so that nobody could hear you?

  Yes
  No
  Possibly
  I choose not to answer

Have you ever had a traumatic experience while in a restroom?

  Yes
  No
  I'm not sure at this time
  I choose not to answer

Would you be able to provide an observed urine sample?

  Yes
  No
  I'm not sure at this time
  I choose not to answer

Do you use a catheter for whenever you need to use the washroom?

  Yes
  Only sometimes
  No
  I'm getting a catheter and plan on doing this
  Other
  I choose not to answer

Do you habitually hold in your urine?

  Yes
  Only when somebody's around
  No
  I don't know at this time
  I choose not to answer

Are you taking medication for a UTI (Urinary Tract Infection)?

  Yes
  No
  I have in the past
  I choose not to answer