Section 4
1) Do you leak urine with sneezing/ coughing/ standing or on activity?
If yes, how often?
How much does this bother you?
0
1
2
3
4
5
6
7
8
9
10
2) Do you need to rush to the toilet to empty your bladder?
If yes, how often?
How much does this bother you?
0
1
2
3
4
5
6
7
8
9
10
3) Does your bladder leak before you can make it to the toilet?
If yes, how often?
How much does this bother you?
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
1
2
3
4
5
6
7
8
9
10
5) Do you feel you do not empty your bladder to completion?
6) Do you need to rush to the toilet to empty your bowels?
If yes, how often?
How much does this bother you?
0
1
2
3
4
5
6
7
8
9
10
7) Do you suffer from constipation?
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?
If yes, where do you place the finger?
9) Have you noted a bulge in your vagina?
10) Are you sexually active?
If yes, do you experience any problems (eg. pain, leakage)?
How much does this bother you?
0
1
2
3
4
5
6
7
8
9
10
B. If you are not sexually active, is it because of:
Would you like something done about this?