| 1. | Do you urinate more than every two hours in the daytime? | Y/N |
| 2. | Do you urinate more than once after going to bed? | Y/N |
| 3. | Do you have trouble making it to the toilet in time when you have an urge to go? | Y/N |
| 4. | Do you strain to pass urine or stool? | Y/N |
| 5. | Do you have an urge to go but when you get to the toilet very little urine comes out? | Y/N |
| 6. | Do you lack the feeling that you need use the toilet? | Y/N |
| 7. | Do you often use the toilet “just in case” before you really have the urge to go? | Y/N |
| 8. | Do you feel that you don’t empty your bladder completely? | Y/N |
| 9. | Do you have “triggers” that make you feel like you can’t wait to go to the toilet? (i.e. running water, key in door) | Y/N |
| 10. | Do you leak urine when you cough/sneeze/exercise? | Y/N |
| 11. | Do you experience pelvic pain with prolonged sitting? | Y/N |
| 12. | Do you have difficulty emptying your bowels? | Y/N |
| 13. | Do you experience lower abdominal pressure, vaginal heaviness or a “falling out” feeling? | Y/N |
| 14. | Does your child wet the bed or lose control of their bowels or bladder during the day? | Y/N |
| 15. | Do you have pain with a gynecologist’s exam, inserting a tampon, or with intercourse? | Y/N |
| 16. | Do wear a pad for protection from leaking or soiling? | Y/N |
Rate the following statement as it applies to you today:
My bladder is controlling my life. 0 = not true 10 = completely true
1 2 3 4 5 6 7 8 9 10
If you answer yes to any of these questions you could benefit from conservative treatment for your bladder. Talk with your health care provider for a referral.