Please click on the answer that best describes your experience. This Urinary Incontinence Assessment tool is an aid to help speed up the process of assessing the condition of someone who may have urinary incontinence. Before visiting the doctor, take a few moments to answer the following questions. Print out your assessment and take it with you when you see the doctor.

Answer Yes, No, or Unsure for each question. Yes No Unsure
1 Do you leak urine?

2 Do you experience urgency when you need to urinate?

3 Do you leak urine when you cough, laugh, sneeze, or do an activity that strains your pelvis or bladder?

4 When you urinate, is it accompanied by a burning sensation?

5 Have you ever had a urinary tract infection or been diagnosed with an enlarged prostate?

6 Do you leak urine at night?

7 Do you dribble urine even after you've finished urinating?

8 Is it difficult to urinate?

9 Do you make frequent trips to the toilet to avoid "having an accident," i.e., leaking urine?

10 Do you wear anything to absorb urine, such as absorbent products (absorbent pads, briefs, or underwear)?

11 Do you get up more than twice in the night to urinate?

12 Is your sleep affected by urine leakage?

13 Is your ability or desire to exercise or lead an active life affected by urine loss?

14 Do you avoid going shopping or doing other activities outside your home because of urine leakage?

15 Are you taking any medications?

16 Do you have any pain with your bowel movements, or have constipation or diarrhea?

17 Are your personal relationships affected by a frequent need to urinate or urine leakage?

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