The Sisterhood Health Forum Registration

Take Control Of Your Bladder

Laugh and share at this FREE women’s event. Bring your mother, sister, and best friend. They’ll thank you for it!

Join Us At The Sisterhood Health Forum

Join us at the Sisterhood Health Forum - Chicago

* Required Field

*Name:

*Email:

*Street Address:

*City:

*State:

*ZIP Code:

*Telephone Number:

*Which event would you like to attend?

6:00 pm - 9:30 pm

How did you hear about the upcoming women’s forum?

Year of your birth:

Optional Information

Opt in Survey disclaimer: The Pelvic Health Foundation respects the confidentiality of your personal information. Your name and responses will be shared only with event sponsors so they can follow up with information that may be helpful to you. This information will not be shared with nor sold to any other outside company.

Which of the following best describes your pelvic floor disorder?

Going to the bathroom frequently
Leaking urine with you laugh, cough or sneeze
Needing to go to the bathroom suddenly
Heavy Bleeding
Pelvic discomfort
Unsure

Have you been diagnosed with any of the following conditions?

Over Active Bladder (OAB)
Retention
Incontinence
Prolapse
Fibroids
Menorrhagia
Unsure

What type of medical doctor provides primary treatment for your pelvic floor problem?

General/Family Practitioner
Urologist
Gynecologist
Urogynecologist
Other

Has your physician discussed surgical options?

How long have you been on prescribed medication for your pelvic floor condition?

I have never been on medications
I am currently taking medication for less than 6 months
I am currently taking medication and have been taking it for more than 6 months
I have been on medications in the past but have stopped taking them