Not A tittte Some- Quite A great A very
How bothered have you been by... a[[ bit what a bit
at deal great deal
1. Frequent urination
during the daytime hours?
2. An uncomfortable
urge to urinate? 0 2 4
3. A sudden urge to urinate
with tittl.e or no warning? 0 4 5
4. Accidental loss of sma[[
amounts of urine?
5. Nighttime urination? 0 4
6. Waking up at night
because you had to urinate? 0 4
7. An uncontrotlable
urge to urinate? 0 4
8. Urine loss associated with
a strong desire to urinate?
Are you male? If male E add 2 points to your score
Please add up your responses to the questions above t][
Answer the followingT questions
based on your experiences during the
past month. (Please circle your answers.)
1. How often have you had the sensation of not
emptying your bladder completely after you
frnished urinatine?
2. How often have you had to urinate again less
than 2 hours after you finished urinating?
3. How often have you found you stopped and
started several times when you urinated?
4. How often do you find it difficult to
postpone urination?
5. How often have you had a weak urinary
stream?
6. How often have you had to push or sffah to
begin urination?
7. How many times did you most typically get
up to urinate from the time you went to bed
at night until the time you got up in the
morning?
PLEASE TOTAL THE NUMBERS YOU CIRCLED
Mild (0-7) Moderate (8-19) Severe (20-35)
QUALITY OF LIFE (QOL)
How would you feel if you were to spend the rest of your iife with your utinary condition just the way it is now?