Sample-ICIQ-UI-Short-Form
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 Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Are you (pick one)
Female
Male
1. How often do you leak urine? (Tick one box)
Never (0)
once per week (1)
2-3 times a week (2)
once per day (3)
several times per day (4)
all the time (5)
2. How much urine do you think leaks (whether you wear protection or not)?
none (0)
a small amount (2)
a moderate amount (4)
a large amount (6)
3. Overall, how much does leaking urine interfere with your everyday life?
Not at all
0
1
2
3
4
5
6
7
8
9
A great deal
10
0 is Not at all, 10 is A great deal
ICIQ Sum Score 1+2+3
4. When does urine leak? (Please tick all that apply to you)
Never
Leaks before you can get to the toilet
Leaks when you cough or sneeze
Leak when you are asleep
Leaks when you exercise
Leaks when you have finished urinating and are dressed
Leaks for no obvious reason
Leaks all the time
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