Medical History
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
What is your Gender?
*
Male
Female
Prefer not to answer
Part 1: General Impact Questions:
1)General Health Perception
*
Very Good
Good
Fair
Poor
Very Poor
2)Incontinence Impact:
*
A lot (Most of the time)
Moderately (Some of the time)
A little
Not at all
Part 2: Lifestyle Limitations:
3a)Does your bladder affect your household tasks?
*
A lot
Moderately
Slightly
Not at all
3b)Does your bladder problem affect your job or your normal daily activities outside of your home?
*
A lot
Moderately
Slightly
Not at all
4a)Does your bladder problem affect your physical activities (walking, running, sport, gym)?
*
A lot
Moderately
Slightly
Not at all
4b)Does your bladder problem affect your ability to travel?
*
A lot
Moderately
Slightly
Not at all
4c)Does your bladder problem affect your social life?
*
A lot
Moderately
Slightly
Not at all
4d)Does your bladder problem affect your ability to see and visit friends?
*
A lot
Moderately
Slightly
Not at all
5a)Does your bladder problem affect your relationship with your partner?
*
A lot
Moderately
Slightly
Not at all
5b)Does your bladder problem affect your sex life?
*
A lot
Moderately
Slightly
Not at all
5c)Does your bladder problem affect your family life?
*
A lot
Moderately
Slightly
Not at all
Not Applicable
6a)Does your bladder problem make you feel depressed?
*
A lot
Moderately
Slightly
Not at all
6b)Does your bladder problem make you feel anxious or nervous?
*
A lot
Moderately
Slightly
Not at all
6c)Does your bladder problem make you feel bad about yourself?
*
A lot
Moderately
Slightly
Not at all
7a)Does your bladder problem affect your sleep?
*
A lot
Moderately
Slightly
Not at all
7b)Does your bladder problem make your feel worn out and tired?
*
A lot
Moderately
Slightly
Not at all
8a)Do your pads to keep you dry?
*
A lot
Moderately
Slightly
Not at all
8b)Do you have to be careful about how much fluid you drink?
*
A lot
Moderately
Slightly
Not at all
8c)Do you change your undergarments because they get wet?
*
A lot
Moderately
Slightly
Not at all
8d)Do you worry in case you smell?
*
A lot
Moderately
Slightly
Not at all
Part 3: Chose the problems that YOU HAVE PRESENT TIME, select NOT APPLICABLE for those questions that don't apply:
FREQUENCY: Does going to the toilet very often affect you?
*
A lot
Moderately
A little
Not applicable
NOCTURIA: How much does getting up at night to pass urine affect you?
*
A lot
Moderately
A little
Not applicable
URGENCY: How do ups have a strong and difficult to control the desire to pass urine?
*
A lot
Moderately
A little
Not applicable
URGE INCONTINENCE: How often do you have urinary leakage associated with a stronger desire to pass urine?
*
A lot
Moderately
A little
Not applicable
STRESS INCONTINENCE: How often do you have urinary leakage associated with physical activity (coughing, running, laughing, sneezing)?
*
A lot
Moderately
A little
Not applicable
NOCTURAL ENURESIS: How often do you have issues wetting the bed?
*
A lot
Moderately
A little
Not applicable
INTERCOURSE INCONTINENCE: How often do you have issues with urinary leakage with sexual intercourse?
*
A lot
Moderately
A little
Not applicable
WATERWORKS INFECTIONS: How often do you have issues with infections from urinary leakage?
*
A lot
Moderately
A little
Not applicable
BLADDER PAIN: How often do you have issues with bladder pain?
*
A lot
Moderately
A little
Not applicable
General Health Perception Calculation
Incontinence Impact Calculation
Role Limitations Calculation
Physical Limitations Calculation
Social Limitations Calculation
Social Limitations Calculation if answer to 5c is Not Applicable
Personal Relationship if 5a+5b>2 Calculation
Personal Relationship if 5a+5b=1 Calculation
Personal Relationship if 5a+5b=0 Calculation
Emotions Calculation
Sleep/Energy Calculation
Severity Measures Calculation
Part 3 Total
Submit
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