Name *

First Name

Last Name

Phone *

(###)

###

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Do you know (or can you estimate) how many times the learner typically urinates in a 24-hour period?

1-2 times

3-5 times

6-9 times

10 times or more

unsure

Do you know (or can you estimate) how many times the learner typically has a bowel movement in a 24-hour period?

1 time

2 times

3 times

4+ times

the trainee does not have daily bowel movements

unsure