Maritime Women's Bladder Health Diagnosing Incontinence Urinary
Urinary Incontinence
Stress Incontinence
Urgency Incontinence
Mixed Incontinence
Overflow Incontinence
What Type of Incontinence do I Have?










Do I Have Incontinence?

Answer this questionnaire to find out what type of incontinence you have and what you can do to help yourself.

Please answer the following questions about your bladder/urinary problem(s).

A. Age:



B. How long have you had your urinary incontinence problem?
 No. of Years    No. of Months   Not Applicable



C. How did your urinary incontinence problem begin?
Gradually   Suddenly   Not Applicable



D. Over the past 6 months, how has your urinary incontinence been?
Getting Worse   Stable   Improving   Changeable   Not Applicable



E. How many trips do you make to the bathroom each day?
2-4   5-7   8-10   more than 10



F. How many of your trips to the bathroom happen because you get a sudden urge to empty your bladder?
0-25%   26-50%   51-75%   76-100%



G. How often do you leak urine during your urgent trips to the bathroom?
0-25%   26-50%   51-75%   76-100 %

Choose the answer that best describes how your bladder works.

1. I leak urine when I cough, laugh, sneeze or move:
Never   Rarely   Sometimes   Usually   Always



2. I leak urine when I play sports, jump or run:
Never   Rarely   Sometimes   Usually   Always



3. I leak urine during intercourse:
Never   Rarely   Sometimes   Usually   Always



4. I leak urine with change of position or other normal daily activities (e.g. - reaching up to a cupboard or carrying groceries):
Never   Rarely   Sometimes   Usually   Always



5. When I need to pass urine it is urgent:
Never   Rarely   Sometimes   Usually   Always



6. I leak a large amount of urine when it is urgent and I do not get to the toilet in time:
Never   Rarely   Sometimes   Usually   Always



7. I have to go to the toilet to pass urine if I hear/put my hands in water:
Never   Rarely   Sometimes   Usually   Always



8. I can't make it to the toilet to pass urine when I first get up in the morning:
Never   Rarely   Sometimes   Usually   Always



9. My bladder problem is worse if I drink caffeine (coffee, tea, cola), alcohol, or fruit juice:
Never   Rarely   Sometimes   Usually   Always



10. I get the urge to pass urine when I arrive home and the key is in the door or my hand is on the doorknob:
Never   Rarely   Sometimes   Usually   Always



11. I pass urine more than seven times in an average day:
Never   Rarely   Sometimes   Usually   Always



12. I carry changes of underwear in case I have an "accident" and leak urine:
Never   Rarely   Sometimes   Usually   Always



13. If I am going out, I will go to the toilet and pass urine, "just in case":
Never   Rarely   Sometimes   Usually   Always



14. Because of my bladder problem, I plan my shopping and/or outings around toilets:
Never   Rarely   Sometimes   Usually   Always



15. My urinary problems make travel by car, bus, train, or plan more difficult (e.g. - I have to stop more often to go to the bathroom when driving in a car):
Never   Rarely   Sometimes   Usually   Always



16. I have to do more laundry because of my urinary leakage:
Yes   No



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