Overactive Bladder Assessment Tool

Overactive Bladder Assessment Tool

Version 06.08.23
Name

First NameLast Name
Date of birth:

MonthDayYear
Date
Phone Number
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How do I use this Assessment?

Read this list of questions and answer them based on the last month. Then bring your completed assessment to your health care provider. This assessment and your answers will make it easier for you to start talking about your symptoms. The questions will help measure which Overactive Bladder (OAB) symptoms you have and how much your symptoms bother you. The better your health care provider knows the level and impact of your symptoms, the better he or she can help you manage them.

SYMPTOM QUESTIONS

Rows	Not at all (0)	Occasionally (1)	About once a day (2)	About three times a day (3)	About half the time (4)	Almost always (5)
1. Urgency – How often do you have a strong, sudden urge to urinate that makes you fear you will leak urine if you can’t get to a bathroom immediately?
2. Urgency Incontinence – How often do you leak urine after feeling a strong urge to go? (whether you wear pads/protection or not)

Rows	None (0)	Drops (1)	1 Tea- spoon (2)	1 Table- spoon (3)	1⁄4 cup (4)	Entire bladder (5)
3. Incontinence – How much urine do you think usually leaks? (whether you wear pads/protection or not)

Rows	1-6 times (0)	7-8 times (1)	9-10 times (2)	11-12 times (3)	13-14 times (4)	15 or more times (5)
4. Frequency – How often do you urinate during the day?

Rows	None (0)	1 time (1)	2 times (2)	3 times (3)	4 times (4)	5 times or more (5)
5. Waking to urinate – How many times do you usually get up at night to urinate, from when you went to bed until you get up in the morning?

TOTAL SYMPTOM SCORE: add score from question 1+2+3+4+5=
(This will be filled by Metro Atlanta Urology and Pelvic Health Center staff)
*If you score 0 on question 1, you probably don’t have OAB.

0 = no symptoms
5 = most severe symptoms
QUALITY OF LIFE QUESTIONS
How much does this bother you:
1b. Urgency – a strong, sudden urge to urinate that makes you fear you will leak urine if you can’t get to a bathroom immediately?

0

1

2

3

4

5

0 is I am not bothered at all, 5 is I am bothered a great deal
2b. Urgency Incontinence – leaking after feeling an urge to go?

0

1

2

3

4

5

0 is I am not bothered at all, 5 is I am bothered a great deal
3b. Frequency – urinating frequently

0

1

2

3

4

5

0 is I am not bothered at all, 5 is I am bothered a great deal
4b. Waking from sleep to urinate?

0

1

2

3

4

5

0 is I am not bothered at all, 5 is I am bothered a great deal
5b. Overall satisfaction – If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?

0

1

2

3

4

5

0 is I would not be bothered at all, 5 is I would be bothered a great deal
6b. How have your symptoms changed your life? – How have your symptoms (urgency, frequency, urine leakage, and waking at night) changed your life? Are your symptoms: (Please check all that apply)
Score the "bother" questions (1b, 2b, 3b, 4b, 5b, & 6b) separately.
Do not add them together.
(This will be filled by Metro Atlanta Urology and Pelvic Health Center staff)
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