INCONTINENCE QUESTIONNAIRE FOR WOMEN

How long have you had the problem of urinary leakage?

Have you ever been evaluated before for this problem?

What test did you have performed and do you know the results?

Have you been treated for urinary leakage before? Is so what treatment (exercises, medications, surgery)?

Please list all of your medications including aspirin and vitamins:
How may times were you pregnant? Vaginal deliveries:
Please list all of your previous surgical procedures?

Have you had back injury or surgery on your back or spinal cord?

Do you have double vision?

Do you have diabetes (sugar)?

Do you have muscle weakness, paralysis, tremors, numbness or tingling in your hands or feet?

Do you have a chronic cough?

Do you have a history of bladder infections (cystitis)?

Do you have any problems engaging in intimacy with your partner?

Characterisation of Urinary Leakage

• Do you lose urine with any of the following:
• Laughing
• Lifting
• Active exercise
• Minimal exercise like walking or light house work
• Sleeping
• Nervousness or increased anxiety
• Leakage unrelated to any specific cause

Is your clothing damp, wet, or soaking wet?

Do you use sanitary napkins, tissue paper, or pads?

How many protective pads do you change per day?

Are they damp, wet, or saturated at each change?

Do you leave puddles of urine on the floor?

Do you lose urine by continuous dribbling?

Do you lose urine in small spurts?

If "yes" is the loss of urine related to physical activity?

Do you lose urine in sudden, large amounts as if your whole bladder has emptied uncontrollably?

When you have the desire to urinate do you lose urine before you can get to the bathroom or toilet?

If "yes" does the urine loss occur every time, half the time, or only occasionally?

How has the problem of incontinence affected your quality of life?