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UW Health SMPH
American Family Children's Hospital
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Register for Clinical Trial

Thank you for your interest in the Post Void Dribbling clinical trial. Please complete the form below.
 
Please do not submit urgent questions about your medical care through this website. If you are experiencing a life- or limb-threatening emergency, call 911. If your need is urgent, call your clinic for assistance.
 

Name (First and Last)
 
Address (Include City and ZIP Code)
 
E-mail Address
 
Phone Number (Include Area Code)
 
Best time to reach you between 9am-4pm:
 
Please answer the following questions to aid in the screening process.
(Optional, also can be done over the phone)
 
1. Do you have symptoms of post void dribbling at least two times per week?
Yes  No 
 
2. Are you between the ages of 18 and 89?
Yes  No 
 
3. Are you pregnant or planning to become pregnant?
Yes  No 
 
4. Do you have any type of kidney or liver disease?
Yes  No 
4a. If yes, are you in kidney failure or liver failure?
Yes  No Not applicable 
 
5. Have you had bladder cancer?
Yes  No 
 
6. Do you have severe chronic constipation?
Yes  No 
 
7. Do you have glaucoma?
Yes  No 
 
8. Are you being treated with now or have you ever been treated with any of the following medications?
darifenacin (Enablex)
fesoterodine (Toviaz)
hyoscyamine (Levsin)
oxybutynin (ditropan)
solifenacin (Vesicare)
tolterodine (Detrol)
trospium (Sanctura)
I have never taken any of these medications
I have not taken any of these medications in the past four weeks
I have taken one or more of these medications in the past four weeks