Select one
answer for each of the statements below that best reflects your situation. Please keep in mind that
this is a general assessment. Further and more
in-depth assessment may be obtained from your health care provider.
| Do you experience a leakage of urine
that impacts your activities? |
|
| Do you experience a
leakage of stool that impacts your activities? |
|
|
Do you experience a leakage of urine causing embarrassment? |
|
| Do you experience a leakage of stool
causing embarrassment? |
|
| Have you noticed a leakage of urine
after childbirth or after an operation, such as a
hysterectomy? |
|
| Do you experience an urgent need to
rush to the bathroom and/or loss of urine or stool if you do
not arrive in time? |
|
| Do you have frequent bladder
infections? |
|
| Are you urinating more frequently than
usual in the absence of a bladder infection? |
|
| Do you experience pain in the bladder
and/or during urination in the absence of a bladder
infection? |
|
| Do you experience an inability to
urinate (known as urinary retention)? |
|
| Have you noticed a progressive
weakness of the urinary system with or without a feeling of
incomplete bladder emptying? |
|
| Have you experienced changes in
urination or defecation related to a neurological condition,
such as stroke, spinal cord injury or multiple sclerosis? |
|
