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