Incontinence Risk Assessment


The following questionnaire gives a sense of the likelihood of having or developing incontinence.

Do you experience urine, stool, or gas leakage sometimes when you cough, laugh, sneeze, or exert yourself physically?
Do you experience urine, stool, or gas leakage that affects your ability to participate in activities? Yes No
Have you experienced urine, stool, or gas leakage after childbirth or after a surgical procedure? Yes No
Do you feel the need to pass urine, stool, or gas more frequently than normal? Yes No
When you feel the need to pass urine or stool, is the feeling often urgent? Yes No
If you can’t get to the bathroom quickly, do you experience leakage of urine or stool? Yes No
Do you experience pain during urination or pain specifically in the bladder during urination, or both? Yes No

Do you often develop bladder infections?

Yes No
Do you sometimes have difficulty in urinating? Yes No
Does your urinary stream seem to have become weaker? Yes No

Does it sometimes feel as though your bladder is not emptying completely?

Yes No
Have you suffered any conditions that might have damaged nerves affecting continence (such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, spinal injury, or stroke)? Yes No
Do you notice urine leakage more often just before your period? Yes No
Have you noticed urine leakage more since menopause? Yes No

Do you have vascular disease caused by diabetes or other condition?

Yes No

Are you over age 50?

Yes No

Are you overweight?

Yes No
Do you experience smoker’s cough? Yes No

Do you often wake at night with the need to urinate?

Yes No

The more often you answered “Yes” to the above questions, the greater your risk for developing or already having incontinence.  If you answered “Yes” to questions above, consider discussing incontinence with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.