QUID: Questionnaire for female Urinary Incontinence Diagnosis

QUID: Questionnaire for female Urinary Incontinence Diagnosis
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Please answer the following 5 questions. Do you leak urine (even small drops), wet yourself, or wet your pads or undergarments in the following situations:
1. ..when you cough or sneeze?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
2. ..when you bend down or lift something up?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
3. ..when you walk quickly, jog, or exercise?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
4. ..while you are undressing in order to use the toilet?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
5. ..Do you ever get such a strong and uncomfortable need to urinate that you leak urine (even small drops), or wet yourself before reaching the toilet?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
6. ..Do you ever have to rush to the bathroom because you get a sudden, strong need to urinate?*

NeverRarelyOnce in a whileOftenMost of the timeAll of the time
SUI Score (max 15)
Urge Score (max 15)
Should be Empty: