These questions ask about symptoms you may have related to urine leakage. Please pick the response that best represents how frequently you experience the symptom.
1.
 Does coughing gently cause you to lose urine? (Would you say..)
Never    Rarely    Sometimes    Often
2.
 Does coughing hard cause you to lose urine? (Would you say…)
Never    Rarely    Sometimes    Often
3.
 Does sneezing cause you to lose urine?
Never    Rarely    Sometimes    Often
4.
 Does lifting things cause you to lose urine?
Never    Rarely    Sometimes    Often
5.
 Does bending cause you to lose urine?
Never    Rarely    Sometimes    Often
6.
 Does laughing cause you to lose urine?
Never    Rarely    Sometimes    Often
7.
 Does walking briskly or jogging cause you to lose urine?
Never    Rarely    Sometimes    Often
8.
 Does straining, if you are constipated, cause you to lose urine?
Never    Rarely    Sometimes    Often
9.
 Does getting up from a sitting to a standing position cause you to lose urine?
Never    Rarely    Sometimes    Often
10.
 Some women receive very little warning and suddenly
find that they are losing, or are about to lose urine beyond their control.
How often does this happen to you? (Would you say….)
Never    Rarely    Sometimes    Often
11.
 If you can't find a toilet or find that the toilet
is occupied, and you have an urge to urinate, how often do you end up losing
urine or wetting yourself? (Would you say….)
Never    Rarely    Sometimes    Often
12.
 Do you lose urine when you suddenly have the feeling that your bladder is very full?
Never    Rarely    Sometimes    Often
13.
 Does washing your hands cause you to lose urine?
Never    Rarely    Sometimes    Often
14.
 Does cold weather cause you to lose urine?
Never    Rarely    Sometimes    Often
15.
 Does drinking cold beverages cause you to lose urine?
Never    Rarely    Sometimes    Often


      

 

<< Back | Next Page >>

All rights reserved by UITN