Fill in, print and take to your doctor

This questionnaire is for you to take to your doctor for them to make a better assessment about your condition. We do not ask for any personal information, this is between you and your doctor. If you wish to learn more about incontinence please visit www.candgmedicare.com your incontinence specialist team.

* 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 4-6 timer per night
More than 6 times

* 2. Dribbling

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

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

* 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
Frequent visits to the toilet to pass water
Urine smells
Amount of urine passed on each visit
I feel I want to push my pelvic area downward after urinating

* 6. I have bowel incontinence

* 7. Confusion episodes

* 8. I have recently had surgery

* 9. Do I have vaginal atrophy?

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

* 10. I feel completely bloated

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