ICIQ-UI Short Form

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Many people leak urine some of the time. We are trying to find out how many people leak urine, and how much this bothers 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.

Name *

First

Last

Phone *

Date / Time *

Date

Time

Please write in your date of birth: *

Are you *

Male
Female

How often do you leak urine? *

never
about once a week or less often
several times a day
about once a day
several times a day
all the time

We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? *

none
a small amount
a moderate amount
a large amount

Overall, how much does leaking urine interfere with your everyday life?

Selected Value: 0

Please ring a number between 0 (not at all) and 10 (a great deal)

When does urine leak? *

never – urine does not leak
leaks before you can get to the toilet
leaks when you cough or sneeze
leaks when you are asleep
leaks when you are physically active/exercising
leaks when you have finished urinating and are dressed
leaks for no obvious reason
leaks all the time

(Please tick all that apply to you)