Incontinence intake that captures leakage type and duration up front
Patients describe their leakage pattern, how long it's been happening, and whether they've noticed blood in the urine, then submit a bladder diary and medication list before the lead ever lands in your CRM.
Preview your incontinence evaluation intake
Explore 6 questions from the Incontinence Evaluation template. This interactive preview uses illustrative scoring and sample attachments. Open the full survey to try the complete intake.
What a qualified incontinence evaluation lead should tell you
A structured intake to capture the pattern, duration, and severity of involuntary urine leakage, flag red-flag symptoms like blood in urine, and confirm the patient can attend an in-person evaluation before a slot is booked.
- Would Describe Type Leakage
- Long Has This Issue
- This Problem Been Evaluated
- Leakage Affecting Daily Activities
- Noticed Blood In Urine
- Able Attend In-Person Urology
The questions your team needs answered
Every incontinence evaluation intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| How would you describe the type of leakage experienced? | The leakage pattern selected points staff toward the likely clinical category before the visit, since stress, urge, and constant leakage often need different exam focus. |
| How long has this issue been happening? | Duration gives context on chronicity even though it carries no weight, helping staff distinguish a new complaint from a longstanding untreated issue. |
| Has this problem been evaluated by a doctor before? | Knowing whether the issue has already been evaluated tells staff whether this is a fresh workup or a case that may need a different approach than a first visit. |
| Is the leakage affecting daily activities or quality of life? | A yes on quality-of-life impact is weighted as an urgency signal, since functional impact often means the patient needs a sooner slot than someone with mild, incidental leakage. |
| Have you noticed blood in the urine or signs of infection? | Blood in urine carries the highest weight in the catalog because it can signal infection or another condition that needs triage ahead of a routine incontinence evaluation. |
| Are you able to attend an in-person urology appointment for this evaluation? | Confirming in-person availability protects against booking a physical exam slot for a patient who can't attend, letting staff offer an alternative instead. |
How Cliont scores incontinence evaluation leads
Configured answer weights help your team prioritize follow-up. Your team reviews each submission and decides the next step.
Value signals
- With activity, coughing, or sneezing
- Constant or frequent dribbling
- A mix of these or not sure
- Leakage Affecting Daily Activities: yes
- Noticed Blood In Urine: yes
- Able Attend In-Person Urology: yes
Urgency signals
- Sudden strong urge before leaking
- Leakage Affecting Daily Activities
See an example lead handoff
Illustrative lead details and score show how a submission can reach your team.
Incontinence Evaluation Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for incontinence evaluation workflows
| Cliont capability | Incontinence Evaluation application |
|---|---|
| Weighted scoring | Answers on leakage type, quality-of-life impact, and blood in urine carry the heaviest weights, so patients with functional impact or possible infection surface above routine leakage inquiries. |
| Conditional flagging | A positive blood-in-urine answer is treated as a red flag separate from standard incontinence scoring, prompting staff to review before slotting the patient into a routine evaluation. |
| Document collection | The intake requests a bladder diary and medication list up front, so staff can review symptom history without chasing paperwork after the appointment is booked. |
| CRM routing | Qualified patients arrive in your CRM tagged with their leakage type and duration answers, so front desk staff can prep the right exam without re-asking intake questions. |
| Fit filtering | Patients who can't attend an in-person visit are marked as lower fit for a standard slot, helping staff redirect them to telehealth instead of losing a booking to a no-show. |
Example incontinence evaluation lead scenarios
Illustrative situations explain the intake questions and possible follow-up.
Stress leakage with activity
Patient reports leakage tied to coughing, sneezing, or exercise and confirms it's affecting daily life, producing a high-value, urgent lead worth prompt scheduling.
Sudden urge-driven leakage
Patient selects sudden strong urge before leaking and flags quality-of-life impact, a distinct pattern from stress incontinence that the intake still routes as urgent.
Possible infection flagged
Patient reports blood in the urine alongside leakage, which the intake weights heavily so staff can triage for infection or urgent urology review before a standard evaluation slot is booked.
Long-standing, never evaluated
Patient describes constant dribbling lasting more than 6 months and has never seen a doctor about it, giving your team chronicity context even though the duration answer itself carries no weight.
Can't attend in person
Patient can't make an in-person visit, which lowers the lead's fit for a standard exam appointment and signals staff should offer a telehealth or alternate pathway instead.
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Notify your team
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Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More urology intake templates
Incontinence Evaluation lead-intake FAQs
How does the intake tell stress incontinence apart from urge incontinence?
The leakage-type question gives patients distinct options for activity-triggered leakage, sudden urge, constant dribbling, or a mix, and each option is weighted so your team can see the likely pattern before the visit.
Does the intake flag blood in the urine as an urgent case?
Yes, a positive answer on the blood-in-urine question carries the highest weight in the catalog, so those leads surface as high priority rather than sitting in a routine evaluation queue.
What happens if a patient says they can't attend an in-person appointment?
That answer is weighted low for fit, so the lead is marked differently than a patient who confirms in-person availability, letting staff decide whether a telehealth path makes sense instead of booking a physical exam slot.
Does the duration of symptoms affect the lead score?
The duration question doesn't carry a scoring weight on its own, but it gives your team useful chronicity context alongside the leakage-type and quality-of-life answers.
Can the intake tell if this is a first-time evaluation or a repeat visit for the same issue?
Yes, patients answer whether the problem has been evaluated by a doctor before, which helps staff distinguish a fresh workup from a follow-up on an existing incontinence case.
What do patients need to upload before submitting the intake?
The intake is built to collect a bladder diary if one exists, a current medication list, and any prior urology or referral notes, so your team has documentation on hand before the first visit.
Turn incontinence evaluation visitors into qualified patients
Give every incontinence evaluation visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.