FEMALE INCONTINENCE QUESTIONNAIRE

Patient Name______________________________________Date___________________
Do you have leakage with:
Coughing or sneezing?
Lifting?
Active exercise? (running, intercourse, etc)
Minimal exercise? (Walking, light housework, etc)
Sleeping?
Nervousness or increased anxiety?
Leakage unrelated to any cause?

Yes_______ No_______
Yes_______ No_______
Yes_______ No_______
Yes_______ No_______
Yes_______ No_______
Yes_______ No_______
Yes_______ No_______

Is your clothing Damp _________Wet __________or Soaking Wet? __________

For protection do you use: Kotex Pads______ Tissue ______or Diapers? ______
How many protective pads do you use per day? __________
Are they Damp ______ Wet ______ or saturated _______ at each change?
Do you leave puddles of urine on the floor?
Yes _______ No_______
Do you lose urine by continuous dribbling?
Yes _______ No_______
Do you lose urine in small spurts?
Yes _______ No_______
If yes, is it related to physical activity
Yes _______ No_______
When you have the desire to urinate, do you lose urine
before you can get to the toilet?
Yes _______ No_______
Do you get severe urge:
In the cold weather?
Yes _______ No_______
With running water?
Yes _______ No_______
At the front door of your home or restroom?
Yes _______ No_______
Do you have pain over your bladder when you are full
Or get the strong urge?
Yes _______ No_______
How often do you pass urine during the day?
Every hour or less _____1-2 hours _____2-3 hours,______,3-4 hours or
greater than 4 hours______
How often do you pass urine after going to bed? ___________________
Is the volume of urine you pass usually?
Large______ average _____small_____ or very small______
Do you empty your bladder frequently, before you experience the desire to pass urine just
so that you will stay dry?
Yes_______ No_______
Please describe in your own word any additional information regarding your
leakage problem not asked above?
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________