Section 4
1) Do you leak urine with sneezing/ coughing/ standing or on activity?
Yes
No
If yes, how often?
Never
Sometimes
All the time
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
2) Do you need to rush to the toilet to empty your bladder?
Yes
No
If yes, how often?
Never
Sometimes
All the time
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
3) Does your bladder leak before you can make it to the toilet?
Yes
No
If yes, how often?
Never
Sometimes
All the time
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
4) How many waterwork/urinary infections have you suffered in the last 6 months?
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
5) Do you feel you do not empty your bladder to completion?
Yes
No
6) Do you need to rush to the toilet to empty your bowels?
Yes
No
If yes, how often?
Never
Sometimes
All the time
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
7) Do you suffer from constipation?
Yes
No
If yes, how do you manage this?
8) Do you ever need to put a finger in your back passage or vagina to help open your bowels?
Yes
No
If yes, where do you place the finger?
9) Have you noted a bulge in your vagina?
Yes
No
10) Are you sexually active?
Yes
No
If yes, do you experience any problems (eg. pain, leakage)?
Yes
No
How much does this bother you? (0 – not at all, 10 – A great deal)
0
1
2
3
4
5
6
7
8
9
10
B. If you are not sexually active, is it because of:
Problems down below in/around the vagina
Social reasons such as you are single, not interested or your partner is unable to etc.
Would you like something done about this?
Yes
No