1. Frequency of urination: awake hour’s      times per day, sleep hours      
2. When you have a normal urge to urinate, how long can you delay before you have to go to the toilet?      minutes,      hours,   not at all       
3. The usual amount of urine passed is:    Please Select Small Medium Large    
4. Frequency of bowel movements      times per day,     times per week, or      .
5. When you have an urge to have a bowel movement, how long can you delay before you have to go to the toilet?      minutes,    hours,   not at all      
6. If constipation is present describe management techniques    
7. Average fluid intake (one glass is 8 oz or one cup) glasses per day.
Of this total how many glasses are caffeinated?      glasses per day.
8. Rate a feeling of organ "falling out" / prolapse or pelvic heaviness/pressure:
   None present
   Times per month (specify if related to activity or your period)
   With standing for minutes or hours.
   With exertion or straining
   Other
Skip questions if no leakage/incontinence
9a. Bladder leakage - number of episodes
   No leakage   
   Times per week
   Times per day
   Times per month
   Only with physical exertion/cough
9b. Bowel leakage - number of episodes
   No leakage   
   Times per week
   Times per day
   Times per month
   Only with exertion/strong urge      
10a. On average, how much urine do you leak?
   No leakage
   Just a few drops
   Wets underwear
   Wets outerwear
   Wets the floor
10b. How much stool do you lose?
   No leakage
   Stool staining
   Small amount in underwear
   Complete emptying
11. What form of protection do you wear?
Please Select None Minimal protection (Tissue paper/paper towel/pantishields) Moderate protection (absorbent product, maxipad) Maximum protection (Specialty product/diaper)    
Other      
On average, how many pad/protection changes are required in 24 hours? #      of pads