Victoria, BC

Victoria Gynecology & Continence Clinic

Incontinence - Quality of Life Questionnaire

Our goal is to provide you with the best service possible. Please complete this questionnaire to help us assist you.

*Please note that unless encrypted, email messages sent via the internet may not be secure and could be intercepted and read by someone else. Please bear this in mind when deciding whether to include personal or sensitive information in any email messages you intend to send. The office of Dr. David Quinlan accepts no responsibility for any information submitted that fails to reach its intended recipient.

If you would prefer to print the form and return it to our office in person, you can download it here: Incontinence - Quality of Life Questionnaire

Incontinence - Quality of Life

I worry about not being able to get to the toilet in time.

 

I worry about coughing or sneezing because of my incontinence.

 

I have to be careful standing up after sitting down because of my incontinence.

 

I worry about where toilets are in new places.

 

I feel depressed because of my incontinence.

 

Because of my incontinence, I do not feel free to leave my home for long periods of time.

 

I feel frustrated because my incontinence prevents me from doing what I want.

 

I worry about others smelling urine on me.

 

Incontinence is always on my mind.

 

It is important to me to make frequent trips to the toilet.

 

Because of my incontinence, it is important to plan every detail in advance.

 

I worry about my incontinence getting worse as I grow older.

 

I have a hard time getting a good night of sleep because of my incontinence.

 

I worry about being embarrassed or humiliated because of my incontinence.

 

My incontinence makes me feel like I am not a healthy person.

 

My incontinence makes me feel helpless.

 

I get less enjoyment out of life because of my incontinence.

 

I worry about wetting myself.

 

I feel like I have no control over my bladder.

 

I have to watch what or how much I drink because of my incontinence.

 

My incontinence limits my choice of clothing.

 

I worry about having sex because of my incontinence.

 

If you would like a copy of your completed form, please click the "Print Page" button below before you click the "Submit Form" button.

*Please note that unless encrypted, email messages sent via the Internet may not be secure and could be intercepted and read by someone else. Please bear this in mind when deciding whether to include personal or sensitive information in any email messages you intend to send. The office of Dr. David Quinlan accepts no responsibility for any information submitted that fails to reach its intended recipient.