TEENLIFTING PELVIC STIMULATION QUESTIONNAIRE
Thank you for your interest in TEENLIFTING rehabilitation. Aim of this questionnaire from MD Sanja Malbasa Gosovic is to diagnose incontinence, hips and back problems and track improvements. If you have any questions regarding rehabilitation feel free to send us e-mail : info@teenlifting.eu TEENLIFTING centre and TEENLIFTING Ltd. are responsible for processing your data in order to offer our services: the electrical muscle stimulation of the face, neck and body. We collect your personal information and information about your health condition. Processing of the above data is mandatory for providing our services.
We consider the confidentiality and security of your information to be of the utmost importance. We will use industry standard physical, technical and administrative security measures to keep your Personally Identifiable Information confidential and secure and will not share it with third parties.
we will use the information you provide on this form to be in touch with you. You can change your mind at any time by contacting us at info@teenlifting.com. We will treat your information with respect. For more information about our privacy practices please visit our website. By clicking below, you agree that we may process your information in accordance with these terms.
If you have any questions, concerns, or requests about this privacy notice, how we manage your Personal Information, or any other issue relating to your Personal Information, please contact us via privacy@teenlifting.eu.

Email address *
Write down the medications that you are currently using and any current medical conditions: *
Your answer
Name and surname: *
Your answer
Year of birth : *
Your answer
Sex: *
Occupation *
Your answer
Country you are from: *
Your answer
Do you suffer from frequent bladder inflammation (burning sensation, frequent urination)? *
Do you occasionally urinate unwillingly when: laughing, sneezing or coughing? *
Do you occasionally urinate unwillingly during strain? *
Do you occasionally urinate unwillingly while lying down? *
Do you always urinate unwillingly? *
Do you sometimes urinate unwillingly, e.g. when having cold? *
Do you wake up at night in order to urinate? *
How often? *
Your answer
Do you use any protection (pads) for your underwear due to uncontrolled urination? *
How often do you change it during the day? *
Your answer
Do you go to the toilet more than 5 times a day? *
Do you often feel an unbearable urge to urinate, although you have urinated just previously? (you can barely make it to the toilet) *
Do you find it difficult to stop urinating when you hear water running from a tap? *
Do you still drip urine shortly after you have turned the tap off? *
Is your stream of urine weak? *
While urinating, do you pass small amounts of urine in several separate flows? *
Have you addressed your doctor due to incontinence so far? *
Do you pass gas without control? *
Do you suffer from external hemorrhoids? *
Do you suffer from hip pain? *
Have you done L/R hip surgery ? *
If yes, how many years ago?
Your answer
Do you suffer from lumbar spine pain? *
Have you undergone prostate surgery? *
If yes, how many years ago?
Your answer
Do you suffer from sexual dysfunction? *
Do you have difficulty with relaxing? *
Do you have problems with: erection / orgasm? *
Have you entered menopause? *
Do you have a regular menstrual cycle? *
Do you suffer from menstrual pain? *
Have you given birth? *
If yes, how many times.
Your answer
How old were you when you had baby for the first time?
Your answer
How old were you when you had your last baby?
Your answer
Was your birth delivery difficult?
Did you have caesarean section?
If yes, how many times?
Your answer
Have you undergone uterus surgery?
If yes, was your uterus removed?
If yes, was your left / right ovary removed?
If yes, how many years ago was it removed?
Your answer
Have you undergone bladder surgery? If yes, when? *
Your answer
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