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Bladder Questionnaire

Bladder Questionnaire
All information on this form will be kept strictly confidential

During the past month:
(Select one answer per question)

1. How often have you felt the strong need to urinate with little or no warning?
    0Not at all
    1Less than 1 time in 5
    2Less than half the time
    3About half the time
    4More than half the time
    5Almost always

2. Is needing to urinate with little warning a problem for you?
    0No problem
    1Very small problem
    2Small problem
    3Medium problem
    4Big problem

3. Is frequent urination during the day a problem for you?
    0No problem
    1Very small problem
    2Small problem
    3Medium problem
    4Big problem

4. Have you had to urinate less than 2 hours after you finished urinating?
    0Not at all
    1Less than 1 time in 5
    2Less than half the time
    3About half the time
    4More than half the time
    5Almost always

5. How often did you most typically get up at night to urinate?
    0None
    1Once
    22 times
    33 times
    44 times
    55 or more times

6. Is getting up at night to urinate a problem for you?
    0No problem
    1Very small problem
    2Small problem
    3Medium problem
    4Big problem

7. Have you experienced pain or burning in your bladder?
    0Not at all
    2A few times
    3Almost always
    4Fairly often
    5Usually

8. Is burning, pain, discomfort or pressure in your bladder a problem for you?
    0No problem
    1Very small problem
    2Small problem
    3Medium problem
    4Big problem

Add the numerical values of the checked entries
ENTER SCORE

9. Do you leak urine when you cough, laugh, sneeze, lift heavy objects or during any other activity?
Y or N

10. Do you notice any pressure in your pelvis or bulging from your vagina?
Y or N

If your score is 10 or more on questions 1-8 and/or if you answer yes to question 9 or 10, talk with your physician about referring you to the Good Samaritan Hospital Women’s Center For Bladder & Pelvic Health for further evaluation.