Name:

Date:

Yes

No 

1. Do you leak when you laugh, cough or sneeze?

2. Do you leak when lifting something heavy?

3. Do you use protective garments/pads in case you leak?

4.  Have you stopped running, jogging, or other activities due to leakage?

5.  Have you delivered more than one baby vaginally?

6.  Do you often need to go to the bathroom more than 7 times a day?

7.  Do you frequently have a strong, sudden urge to urinate?

8.  When traveling, do you have to stop often for a bathroom break?

9.  Do you get up to go to the bathroom more than twice a night?

10.  Do you have to run to the bathroom to avoid leaking?