Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.

1. FEMALE INCONTINENCE QUESTIONNAIRE
Patient Name______________________________________Date___________________
Do you have leakage with:
Coughing or sneezing? Yes_______ No_______
Lifting? Yes_______ No_______
Active exercise? (running, intercourse, etc) Yes_______ No_______
Minimal exercise? (Walking, light housework, etc) Yes_______ No_______
Sleeping? Yes_______ No_______
Nervousness or increased anxiety? Yes_______ No_______
Leakage unrelated to any cause? Yes_______ No_______
Is your clothing Damp _________Wet __________or Soaking Wet? __________
For protection do you use: Kotex Pads______ Tissue ______or Diapers? ______
How many protective pads do you use per day? __________
Are they Damp ______ Wet ______ or saturated _______ at each change?
Do you leave puddles of urine on the floor? Yes _______ No_______
Do you lose urine by continuous dribbling? Yes _______ No_______
Do you lose urine in small spurts? Yes _______ No_______
If yes, is it related to physical activity Yes _______ No_______
When you have the desire to urinate, do you lose urine
before you can get to the toilet? Yes _______ No_______
Do you get severe urge:
In the cold weather? Yes _______ No_______
With running water? Yes _______ No_______
At the front door of your home or restroom? Yes _______ No_______
Do you have pain over your bladder when you are full
Or get the strong urge? Yes _______ No_______
How often do you pass urine during the day?
Every hour or less _____1-2 hours _____2-3 hours,______,3-4 hours or
greater than 4 hours______
How often do you pass urine after going to bed? ___________________
Is the volume of urine you pass usually?
Large______ average _____small_____ or very small______
Do you empty your bladder frequently, before you experience the desire to pass urine just
so that you will stay dry? Yes_______ No_______
Please describe in your own word any additional information regarding your
leakage problem not asked above?
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