Victoria, BC

Victoria Gynecology & Continence Clinic

Urinary Incontinence - Severity Score 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: Urinary Incontinence - Severity Score Questionnaire

Incontinence - Severity Score

Do you experience urine leakage not related to effort or position (for example when lying down)?

 

Do you experience urine leakage related to minor physical activity (for example when walking or rising)?

 

Do you experience urine leakage related to strong physical activity such as coughing or sneezing?

 

Has urine leakage disturbed your daily chores (shopping, cooking, housecleaning, etc.)?

 

Has urine leakage disturbed your employment (client service, work performance, etc.)?

 

Are you afraid others will notice your problem (fear of your odour, wetness etc.)?

 

Do you have to restrict or give up social activities such as visiting friends, physical activity, theatre, church, etc.?

 

Do your incontinence systems disturb your sex life?

 

Does incontinence cause irritation of your external genital organs?

 

How often must you use a protective napkin or pad?

 

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.