Incontinence Quality of Life Questionnaire
Please complete this questionnaire to help us understand how incontinence affects your daily life.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
How frequently do you experience incontinence?
*
Never
Rarely
Sometimes
Often
Always
How much does incontinence affect your daily activities?
*
Not at all
A little
Moderately
Quite a lot
Extremely
Please rate the following aspects of your quality of life as affected by incontinence.
*
Rows
Never
Rarely
Sometimes
Often
Always
Feeling embarrassed
1
2
3
4
5
Limiting social activities
6
7
8
9
10
Feeling anxious or worried
11
12
13
14
15
Disturbed sleep
16
17
18
19
20
Limiting physical activities
21
22
23
24
25
How confident do you feel managing your incontinence?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you avoid certain activities because of incontinence?
*
Yes
No
How satisfied are you with the support or treatment you are receiving?
1
2
3
4
5
Would you like to add any comments or describe how incontinence affects your life?
Submit Questionnaire
Should be Empty: