Which type of incontinence do you have? Survey

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* 1. I have been waking up to go to the bathroom in the night (nocturia)

	Number of visits to the toilet.
Between 1-3 times per night	Between 1-3 times per night Number of visits to the toilet.
Between 4-6 timer per night	Between 4-6 timer per night Number of visits to the toilet.
More than 6 times	More than 6 times Number of visits to the toilet.

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* 2. Dribbling

I am dribbling and need incontinence protection

I dribble when I urinate (the pressure is not there)

I do not dribble and my urine flow is sufficient

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* 3. Do I have urgency (OAB- Over Active Bladder)?

I feel I must rush to the toilet but can not make it and end up wetting myself

I feel I need to go to the toilet if I hear or see running water

I go often to the toilet but only pass small amounts of urine each time

Extra information you should tell your doctor

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* 4. Do I have Stress Incontinence? I leak urine when I ..

Run

Laugh

Cough

Sneeze

Lift something

Stand up after sitting for long periods

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* 5. Do you I have a UTI (Urinary Tract Infection)? Enter severity(0=not at all 5=severe)

	0	1	2	3	4	5
Burining sensation on passing water	Burining sensation on passing water 0	Burining sensation on passing water 1	Burining sensation on passing water 2	Burining sensation on passing water 3	Burining sensation on passing water 4	Burining sensation on passing water 5
Frequent visits to the toilet to pass water	Frequent visits to the toilet to pass water 0	Frequent visits to the toilet to pass water 1	Frequent visits to the toilet to pass water 2	Frequent visits to the toilet to pass water 3	Frequent visits to the toilet to pass water 4	Frequent visits to the toilet to pass water 5
Urine smells	Urine smells 0	Urine smells 1	Urine smells 2	Urine smells 3	Urine smells 4	Urine smells 5
Amount of urine passed on each visit	Amount of urine passed on each visit 0	Amount of urine passed on each visit 1	Amount of urine passed on each visit 2	Amount of urine passed on each visit 3	Amount of urine passed on each visit 4	Amount of urine passed on each visit 5
I feel I want to push my pelvic area downward after urinating	I feel I want to push my pelvic area downward after urinating 0	I feel I want to push my pelvic area downward after urinating 1	I feel I want to push my pelvic area downward after urinating 2	I feel I want to push my pelvic area downward after urinating 3	I feel I want to push my pelvic area downward after urinating 4	I feel I want to push my pelvic area downward after urinating 5

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* 6. I have bowel incontinence

I can't make it to the toilet on time

I am unaware I am losing feacal matter

I lose feacal matter every time I go to the toilet

Bowel incontinence

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* 7. Confusion episodes

I notice confusion/disorientation during the day

I notice confusion/disorientation during the night

Episodes of confusion before a meal

Episodes of confusion after a meal (note what food is eaten)

More information such as medication you take.

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* 8. I have recently had surgery

Bladder surgery

Bowel surgery

Pelvic floor surgery

Other surgery

They have changed my medication

More information

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* 9. Do I have vaginal atrophy?

	Yes	No	I do not know
I am post menopausal	I am post menopausal Yes	I am post menopausal No	I am post menopausal I do not know
I am post operative	I am post operative Yes	I am post operative No	I am post operative I do not know
I am on medication (state which)	I am on medication (state which) Yes	I am on medication (state which) No	I am on medication (state which) I do not know
I am unable to use a tampon	I am unable to use a tampon Yes	I am unable to use a tampon No	I am unable to use a tampon I do not know
I suffer with bleeding from the vagina which is not menstrual blood	I suffer with bleeding from the vagina which is not menstrual blood Yes	I suffer with bleeding from the vagina which is not menstrual blood No	I suffer with bleeding from the vagina which is not menstrual blood I do not know
Intercourse is painful	Intercourse is painful Yes	Intercourse is painful No	Intercourse is painful I do not know

Other (please specify)

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* 10. I feel completely bloated

I can not pass urine (I feel as if there is a blockage)

I think I may have a prolapse

I am unable to open my bowels for days (mention how many days)

When I do open my bowels I feel as if there is more to empty but can not empty fully

My stomach is distended

More information your doctor may need to know