Mediarts questionnaire for female urinary incontinence.

Personal cure solutions for female urinary incontinence and anonymous selfcare.

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Questionnaire for female urinary incontinence:
1	Year of birth:	year
2	Do you smoke?	No Yes
3	Your heigth:	cm.
4	Your weight:	kg.
5	Do you have involuntary urine loss ?
6	How much urine do you lose when urine loss occurs ?
7	Do you use pads for urine loss?
8	Does your urine loss decrease your quality of life ?
9	Does involuntary urine loss occur when you cough, sneeze or laugh ?	No. Yes.
10	Does involuntary urine loss occur during physical activities or sports ?	No. Yes.
11	Does involuntary urine loss occur when you walk ?	No. Yes.
12	Does involuntary urine loss occur when you sleep ?	No. Yes.
13	Does involuntary urine loss occur without any cause ?	No. Yes.
14	For how long have you been experiencing urine loss ?
15	How often do you void at night ?
16	How often do you void during daytime ?
17	Do you have to rush to a toilet if you have a strong urge to void ?
18	Do you have uncontrolable urine loss when you have the urge to void ?
19	What bothers you most ?
20	Do you have pain during voiding ?	No. Yes.
21	Do you have urinary tract infections (more than once a year) ?	No. Yes. I don't know.
22	Has your voiding pattern changed ?	No. Yes. I don't know.
23	You drink per day:
24	How is your voiding stream ?
25	Do you feel that your bladder is empty after voiding ?	No. Yes.
26	Do you have to strain to empty your bladder ?	No. Yes.
27	Do you have an irritating or a burning sensation in the vagina ?	No. Yes.
28	Have you experienced the sensation of tissue bulging out of the vagina ?
29	Do you have vaginal discharge ?	No. Yes.
30	Do you have pain in the lower abdomen ?	No. Yes.
31	Your menopause:
32	Do you have Diabetes Mellitus ?	No. Yes.
33	Do you have glaucoma ?	No. Yes.
34	Do you have a neurologic disease?	No. Yes.
35	Did you have an operation/irradiation of your back, lower belly or vagina ?	No. Yes.
36	Are you sufficiently mobile ?	No. Yes.
37	Did you have psychiatric treatment ?	No. Yes.
38	Did you have blood in your urine ?	No. Yes.
39	Your stools are:
40	So far your treatment for urinary incontinence was:
41	Do you use medication ?	No. Yes.
42	Do/did you use medication for incontinence ?
43	Is your incontinence problem troublesome enough for you to use medication for it ?
44	Is your incontinence problem troublesome enough for you to have an operation ?
45	The questionnaire was ?

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