Incontinence Risk Assessment
The following questionnaire gives a sense of the likelihood of having or developing incontinence.
| Do you experience urine, stool, or gas leakage sometimes when you cough, laugh, sneeze, or exert yourself physically? |
Yes
|
No
|
| Do you experience urine, stool, or gas leakage that affects your ability to participate in activities? | Yes | No |
| Have you experienced urine, stool, or gas leakage after childbirth or after a surgical procedure? | Yes | No |
| Do you feel the need to pass urine, stool, or gas more frequently than normal? | Yes | No |
| When you feel the need to pass urine or stool, is the feeling often urgent? | Yes | No |
| If you can’t get to the bathroom quickly, do you experience leakage of urine or stool? | Yes | No |
| Do you experience pain during urination or pain specifically in the bladder during urination, or both? | Yes | No |
|
Do you often develop bladder infections? |
Yes | No |
| Do you sometimes have difficulty in urinating? | Yes | No |
| Does your urinary stream seem to have become weaker? | Yes | No |
|
Does it sometimes feel as though your bladder is not emptying completely? |
Yes | No |
| Have you suffered any conditions that might have damaged nerves affecting continence (such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, spinal injury, or stroke)? | Yes | No |
| Do you notice urine leakage more often just before your period? | Yes | No |
| Have you noticed urine leakage more since menopause? | Yes | No |
|
Do you have vascular disease caused by diabetes or other condition? |
Yes | No |
|
Are you over age 50? |
Yes | No |
|
Are you overweight? |
Yes | No |
| Do you experience smoker’s cough? | Yes | No |
|
Do you often wake at night with the need to urinate? |
Yes | No |
The more often you answered “Yes” to the above questions, the greater your risk for developing or already having incontinence. If you answered “Yes” to questions above, consider discussing incontinence with one of our Women’s Center healthcare providers.
Print this page and bring it with you, filled out, to your appointment.
