Urinary Distress Inventory, Short Form (UDI-6)
Version 06.08.23
Name
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
For each question, choose the number that best describes this problem for you
over the past
month.
Do you experience and, if so, how much are you bothered by:
*
Not at All (0)
A Little Bit (1)
Moderately (2)
Greatly (3)
Frequent Urination?
Urine leakage related to urgency?
Urine leakage related to physical activity (walking, running, laughing,
sneezing, coughing)
Small amounts of urine leakage?
(drops)
Difficulty emptying your bladder or Difficulty urinating?
Pain or discomfort in your lower abdominal, pelvic, or genital area?
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: