How often do you urinate during the day?
How often do you get up at night to urinate?
Is the amount of urine you usually pass:	Large	Average	Small
Do you usually have a strong sense of urgency to urinate?	No	Yes
Do you have to hurry to empty your bladder when full?	No	Yes
Do you ever not make it in time and leak urine?	No	Yes
Can you overcome the sensation or urgency to urinate?	No	Yes
Does the sight, sound, or feel of running water cause you to lose your urine?	No	Yes
Do you ever lose urine when lying down?	No	Yes
Do you have a warning before losing urine?	No	Yes
When urinating, can you usually stop your stream?	No	Yes
Do you ever accidentally wet the bed while asleep?	No	Yes
Do you have difficulty starting your urine stream?	No	Yes
Do you feel that you completely empty your bladder?	No	Yes
Do you notice dribbling of urine after voiding?	No	Yes
Were you ever catheterized because you were unable to void?	No	Yes
Have you ever had your urethra dilated or stretched?	No	Yes
Do you ever pass blood in your urine?	No	Yes
Have you ever passed sand, gravel or stones?	No	Yes
Do you have pain during urination?	No	Yes
Have you been treated for 3 or more urinary infections?	No	Yes
Have you been treated for an infection within 6 months?	No	Yes
Do you lose urine while coughing, sneezing, laughing, lifting, jumping or running?	No	Yes
Do you find it necessary to use some type of protection?	No	Yes
Did your urinary difficulty begin: During a pregnancy?	No	Yes
Following a delivery?	No	Yes
Following an abdominal or vaginal operation?	No	Yes
After menopause?	No	Yes
List all medications you have taken in the past 6 months.
Circle those medications you are presently taking.