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Assessment Forms

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Below is a list of Forms that, as a patient, you may be asked to complete during the investigation of possible problems. Your consultant will direct you as to which is relavant for you:

ipss

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ipss

Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Urgency Over the last month, how difficult have you found it to postpone urination?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Weak stream Over the past month, how often have you had a weak urinary stream?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Straining Over the past month, how often have you had to push or strain to begin urination?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
Nocturia Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always
ICIQ-IPPS Total score:
Quality of life due to urinary symptoms If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?
0-Not at all1-Less than 1 time in 52-Less than half the time3-About half the time4-More than half the time5-Almost always

iciq ui

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iciq ui

Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much they bother them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

3. How often do you leak urine?
0-Never1-About once a week or less often2-Two or three times a week3-About once a day4-Several times a day5-All the time
4. We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)?
0-None2-A small Amount4-A moderate amount6-A Large Amount
5.Overall, how much does leaking urine interfere with your everyday life? Please select a number between 0 (not at all) and 10 (a great deal)?
12345678910
ICIQ-UI Total score: Sum scores 3 + 4 + 5 Score 0(min) – 21(max)
When does urine leak ? (please tick all that apply to you)
Never urine does not leakLeaks before you can get to the tolietLeaks when you cough or sneezeLeaks when you are asleepLeaks when you are physically active/exercisingLeaks when you have finished urinating and are dressedLeaks for no obvious reasonLeaks all the time

iciq qab

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iciq qab

Many people experience urinary symptoms some of the time. We are trying to find out how many people experience urinary symptoms, and how much they bother them. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS

How often do you pass urine during the day?
1-Hourly2-Every Two Hours3-Every Three Hours4-Every Four Hours or More
How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
During the night, how many times do you have to get up to urinate, on average?
01234 or More
How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
Do you have to rush to the toilet to urinate?
0-Never1-Occasionally2-Sometimes3-Most of the Time4-All of the Time
How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
Do you have to rush to the toilet to urinate?
0-Never1-About once a week or less often2-Two or three times a week3-About once a day4-Several times a day5-All the time
How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
ICIQ-OAB Total score: Sum scores 3a + 4a + 5a Score 0(min) – 16(max)

iciq luts

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iciq luts

Below are some daily activities that can be affected by urinary problems. How much does your urinary problem affect you? We would like you to answer every question. Simply circle the score that applies to you. We would be grateful if you could answer the following questions, thinking about how you have been, on average, over the PAST FOUR WEEKS.

3a. To what extent does your urinary problem affect your household tasks ? Please select a number between 0 (not at all) and 4 (alot)
1234
3b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
4a. Does your urinary problem affect your job, or your normal daily activities outside the home? Please select a number between 0 (not at all) and 4 (alot)
1234
4b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
5a. Does your urinary problem affect your physical activity (e.g. going for a walk, run, sport, gym, etc.)? Please select a number between 0 (not at all) and 4 (alot)
1234
5b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
6a. Does your urinary problem affect your ability to travel? Please select a number between 0 (not at all) and 4 (alot)
1234
7b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
7a. Does your urinary problem limit your sociallife? Please select a number between 0 (not at all) and 4 (alot)
1234
7b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
8a. Does your urinary problem limit your ability to see/visit friends ? Please select a number between 0 (not at all) and 4 (alot)
1234
8b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
9a. Does your urinary problem affect your relationship with your partner? Please select a number between 0 (not at all) and 4 (alot)
1234
9b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
10a. Does your urinary affect your sex life ? Please select a number between 0 (not at all) and 4 (alot)
1234
10b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
11a. Does your urinary problem affect your family life? Please select a number between 0 (not at all) and 4 (alot)
1234
11b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
12a. Does your urinary problem make you feel depressed? Please select a number between 0 (not at all) and 4 (alot)
1234
12b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
13a. Does your urinary problem make you feel anxious or nervous? Please select a number between 0 (not at all) and 4 (alot)
1234
13b. How much does this bother you ? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
14a. Does your urinary problem make you feel bad about yourself? Please select a number between 0 (not at all) and 4 (alot)
1234
14b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
15a. Does your urinary problem affect your sleep? Please select a number between 0 (not at all) and 4 (alot)
1234
15b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
16a. Do you feel worn out/tired? Please select a number between 0 (not at all) and 4 (alot)
1234
16b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
17a. Do you do any of the following? If so how much? Wear pads to keep dry? Please select a number between 0 (not at all) and 4 (alot)
1234
17b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
18a. Do you do any of the following? If so how much? Be careful how much fluid you drink? Please select a number between 0 (not at all) and 4 (alot)
1234
18b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
19a. Do you do any of the following? If so how much? Change your underclothes when they get wet? Please select a number between 0 (not at all) and 4 (alot)
1234
19b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
20a. Do you do any of the following? If so how much? Worry in case you smell? Please select a number between 0 (not at all) and 4 (alot)
1234
20b. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
21a. Do you do any of the following? If so how much? Get embarrassed because of your urinary problem? Please select a number between 0 (not at all) and 4 (alot)
1234
22a. How much does this bother you? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910
ICIQ-LUTS Total score: Sum scores 3a + 4a + 5a--------21a Score 16(min) – 76(max)
Overall, how much do urinary symptoms interfere with your everyday life? Please select a number between 0 (not at all) and 10 (a great deal)
12345678910

bladder diary

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bladder diary

pad test

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pad test

Measuring the volume of urine lost over 24 hrs is a very good way of assessing the severity of incontinence. This is an easy test to perform but must be carried out accurately. You will need a plastic bag without holes that can be tied closed, and big enough to hold all the pads you use in 24 hrs, and be tied closed.

Start the test when you first get out of bed to start your day. If you have worn a pad overnight, throw it away, and put a fresh pad on. Thereafter, put every pad you remove into the plastic bag. Tie it closed to stop any loss, but loosely enough that you can open it to put further pads in. The following morning put the pad you wore overnight into the bag and tie the bag tightly closed. In another plastic bag put a dry pad. If you have a weight scale, weigh the plastic bag with all the wet pads and the plastic bag with the dry pad separately.

The amount of urine you loose/leak can be calculated from the weight of the wet pads you used in 24 hours and equivalent number of dry pads. Weight of wet pads [grams] – Weight of same number of dry pads [grams] = urine loss/leak in 24hrs [grams].

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